Non Qualified Annuity Claimant s Statement

Transcription

1 Non Qualifie Annuity Claimant s Statement The Lincoln National Life Insurance Company Service Office P.O. Box 7880 Fort Wayne, IN Phone: , Ext.* Overnight Aress: Lincoln Financial Group Death Claims - IA 1300 S Clinton St. Fort Wayne, IN Contract Number: Instructions Important Information please rea carefully an completely Annuity Death Claim Items that are always require: Certifie eath certificate showing the manner of eath (non-returnable). Claimant s Statement complete an signe by each beneficiary. Each beneficiary must have a separate Claimant s Statement. Aitional ocumentation an instructions may be require when the beneficiary is a(n): Estate Trust Guarian (minors an incompetent beneficiaries) Corporation Partnership Assignment to thir parties Please refer to the Distinctive Payee Arrangements form (number CL05984A) for full instructions. Power of Attorney: If an attorney-in-fact uner a Power of Attorney is completing the Annuity Claimant s Statement on behalf of the claimant, a copy of the Power of Attorney ocument must be provie. If the Power of Attorney ocument was execute more than three years ago, aitional information from the attorney-in-fact may be require. The Social Security number of the person who grante the Power of Attorney must be use. The attorney-in-fact s Social Security number may not be use. Other Possible Requirements (please note that failure to inclue this information where applicable may cause elay in processing the claim.): Decease Beneficiary if any name beneficiary of the contract is ecease, a copy of the eath certificate of such ecease beneficiary must accompany this form. Foreign Death if eath of the owner/annuitant/participant occurre outsie of the Unite States, we will require a Report of the Death of an American Citizen Abroa an a Foreign Death Questionnaire. A Translate Certifie Copy of the Death Certificate may also be require. Consent to transfer or a state tax waiver A form for consent or notice is require in some states. When consent is require, the state must give approval before the eath benefit can be pai. If this form is require, it will be provie to the beneficiary by us. Variable Annuities: If the contract has money in variable sub-accounts, the money is subject to market fluctuations. You may be able to transfer money to ifferent sub-accounts or to a Fixe account with written authorization signe by all beneficiaries an a copy of the eath certificate. The Lincoln National Life Insurance Company (Lincoln) oes not require that the policy(ies) be returne to Lincoln for filing of a claim. However, Lincoln oes ask that the relevant policy(ies) be estroye once payment is receive. * - Policy may be referre to as Contract or Certificate Lincoln Financial Group is the marketing name for Lincoln National Corporation an its affiliates. Page 1 of 10

2 You can help expeite the payment of your claim by completing all of the information on this page. Contract Number: Decease s Information If the ecease was known by any other names, such as maien name, hyphenate name, nickname, erivative form of the first an/or mile name, please inclue them below: Name: Social Security Number: Date of Birth: Date of Death: Citizenship: Was ecease a U.S. Citizen? h Yes h No Country of Citizenship: Aress: City: State: Zip: Claimant Information Relationship Gener: h Male h Female Claimant s relationship to Deceent: I am filing this claim as: h An iniviual who is a name beneficiary uner the policy. Social Security Number: h A Trustee of a Trust which is a name beneficiary uner the policy. Trust TIN Number: h An Executor of an Estate which is a name beneficiary uner the policy. Estate TIN: h Other: Tax ID Number: Name: Date of Birth: Citizenship: Uner penalties of perjury, I certify that: h The number shown on this form is my correct taxpayer ientification number, I am not subject to backup withholing an I am a US citizen or other US person h I am not a US Citizen. Country of Citizenship: If you are a resient of a foreign country, a W-8BEN or a W-9 must be complete. This form can be foun at: or Aress: City: State: Zip: Primary Telephone No: Seconary Telephone No: Aress: Page 2 of 10

3 For your convenience an assistance when your claim is approve, pages 3 through 5 offer you the ability to receive your eath benefits or place your funs into one of the other payment options. Please rea your options carefully an know that Lincoln is available to aress any questions that you may have. The options are numbere for your convenience. Payment Options: Please select one of the following options. Please Note: If the owner of the Contract/Certificate has previously esignate a payment option, Lincoln is require to isburse funs pursuant to that esignation. Option 1 (Option 1 is a Taxable Event.) h LUMP SUM Three options are provie Metho Of Distribution - Select ONE istribution metho A, B or C METHOD A: CHECK (If no metho of istribution is selecte, will efault to check.) Select One: h Regular Mail (No Fee) Select One: h Overnight Mail ($25 fee, subject to change) h Claimant s Aress h Alternate Aress (complete mailing information below) Name: Aress: City: State: Zip: METHOD B: DIRECT DEPOSIT (ACH, no fee) A check will be issue if all of the irect eposit requirements are not complete. Cannot o irect eposit to a foreign or overseas account. Select One: h Checking - Must attach a copy of a voie check. Account must be in the same name as the beneficiary. h Savings - Must attach the following information on the Financial Institution s letterhea: Routing Number Account Number Accountholer s Name h Brokerage Account - Must attach the following information on the Financial Institution s letterhea: Routing Number Account Number Accountholer s Name METHOD C: WIRE DEPOSIT (wire fees: $25 for omestic; $40 for foreign; all fees subject to change) h Wire Deposit - Must attach the following information on the Financial Institution s letterhea: Routing Number Account Number Accountholer s Name Financial Institution s Name an full Aress Further Creit to Account Number Please procee to the tax withholing section on page 7. Page 3 of 10

4 Option 2 (Only Available for Spousal Beneficiaries) Please procee to the election of beneficiary section on page 8 to change the beneficiary(ies) of this policy. If you o not name a beneficiary, the beneficiary will be your estate. h ASSUME OWNERSHIP As the surviving spouse an sole primary beneficiary of this annuity policy, I wish to be esignate as the successor owner. I unerstan that the policy will remain in force with the original effective ate with no change of policy provisions an no eath benefit istribution will occur. I also unerstan this ownership change is not taxable. Note that the term spouse as use in this Claimant s Statement means a spouse as efine uner Feeral law, which only confers marriage rights an privileges an certain tax benefits to lawfully marrie couples. Current Feeral law efines the term spouse to inclue an iniviual marrie to a person of the same or opposite gener if the iniviuals are lawfully marrie uner state law. The term spouse oes not inclue a omestic partner, civil union partner, or other status that is not recognize as a spouse uner Feeral law. Therefore, the payment option, Assume Ownership, is only available to a surviving spouse of a lawful marriage. If the Dollar Cost Averaging program or the Automatic Withrawal Service program was establishe uner the original contract, it will be terminate. As surviving spouse, you may start a new program. If so, please select one or the other of the following: h Start a new Dollar Cost Averaging program (a separate election form is neee). h Start a new Automatic Withrawal Service program an complete page 6. Option 3 (Please procee to the election of beneficiary section on page 8 to change the beneficiary(ies) of this contract. If you o not name a beneficiary, the beneficiary will be your estate.) h THE i4life ADVANTAGE (Please be aware an aitional form is require to be complete with this option.) Start a new i4life program (a separate election form is neee) This option must begin within one year of the ate of eath. The regular income will be a combination of gain (taxable) an return of the original investment (non-taxable). The minimum account value necessary to elect i4life Avantage is $50,000 an the eath benefit must be the Account Value. Please note, there is a charge associate with this option. Option 4 (Please complete the automatic withrawal service information section on page 6 an procee to the election of beneficiary(ies) section on page 8 to change the beneficiary(ies) uner this policy. If you o not name a beneficiary, the beneficiary will be your estate.) h 5 YEAR DEFERRAL This option is available for eath benefits of $10,000 or more. The claimant must surrener an take full istribution of the procees no later than the fifth anniversary of the eceent s ate of eath. A Five-Year Deferral postpones payment of the procees for up to five years from the original owner s ate of eath. No aitional money may be ae to the policy. Distributions are taxable as they are mae an will be reporte as orinary income on IRS Form 1099-R. You may name your beneficiary(ies) in the election of beneficiary section. The eath benefit payable to your beneficiary at your eath is the account value, with appropriate interest creite. Option 5 (Please complete the automatic withrawal service information section on page 6 an procee to the election of beneficiary(ies) section on page 8 to change the beneficiary(ies) uner this policy. If you o not name a beneficiary, the beneficiary will be your estate.) h EXTENDED PAYOUT - (This option may not be available on all fixe proucts.) For Fixe Contracts a New Application is Require This option is available for eath benefits of $10, or more. With this option, istributions base on the claimant s life expectancy must begin by the first anniversary of the eceent s eath. Distributions are reporte to the claimant for the year in which they are mae on IRS Form 1099-R. All or a portion of each istribution may be taxable an reporte as orinary income; istributions typically come from taxable earnings before coming from the cost basis in the contract. Distributions may be accelerate, but may not be ecrease or stoppe. The eath benefit payable to your beneficiary at your eath is the account value, which may be subject to market fluctuation. Page 4 of 10

5 Option 6 h ANNUITIZATION OPTION (Requires completion of Annuitization Form.) This option is available for eath benefits of $5,000 or more. This option must begin within one year of the Death of the Owner/Annuitant. The selection of this option is irrevocable. Some of the options may not be available in some instances ue to IRS regulations or possible restrictions of the plan in which you may have been participating. Please refer to the Prospectus or to your plan. Life Options: Life Only: Procees are pai in installments as long as you are living. Payments cease at your eath. Life with Perio Certain: Procees are pai in installments as long as you are living. If you ie within the time perio you electe after payments start, we will continue payments to your beneficiary for the balance of the time perio electe. Life with Unit Refun (Variable payout only): Procees are pai in installments as long as you are living. If you ie prior to the return of all units, remaining units will be returne to your beneficiary as a lump sum. Life with Cash Refun (Fixe payout only): Procees are pai in installments as long as you are living. If you ie prior to the return of your premium, remaining funs will be returne to your beneficiary as a lump sum. Life with Installment Refun: Procees are pai in installments as long as you are living. If you ie prior to the return of full premium, we will continue payments to your beneficiary until the premium has been satisfie. Non-Life Options: Installment for a Designate Perio: Procees are pai in equal installment for any number of years you select. (restrictions may apply) Installment for a Designate Amount (100% Fixe payout only): Payments are mae in equal installments of an amount you select until the procees are exhauste. Option 7 h ESTABLISH YOUR OWN CONTRACT This option is available to non-spouse claimants. This option is taxable. The earnings in the contract are reporte as orinary income to the claimant on IRS Form 1099-R. The cost basis in the contract will be ajuste to reflect the amount that has been taxe. A new application is require for each claimant making this election an a new contract will be issue. Option 8 h 1035 EXCHANGE - (This option allows the transfer of funs to another Lincoln contract or another financial/ institution carrier.) h Exchange to another Lincoln contract: Aitional forms require for a Application for the new policy - ACORD 1035 Exchange Rollover an Transfer Form (ACORD 951) - Disclosure Notice h Exchange to another financial institution/carrier: Aitional forms require for a Exchange form from other financial institution/carrier - Acceptance letter from other financial institution/carrier Page 5 of 10

6 Automatic Withrawal Service Information (This service is not available for annuitization options.) Please complete this section if payment option 5 was selecte. This section is optional if payment options 2 or 4 were selecte. Automatic Withrawal Options - Select ONE ( Require Minimum Distribution (RMD) will be the efault amount if amount not specifie) h Withraw $ per payment frequency h Require Minimum Distribution (RMD)/ Life Expectancy Payment rules Payment Information Requeste Start Date (month/year) (Start Date of withrawl efaults to 5 th if Date option not selecte, but recurring withrawl ate efaults to 20 th if option not selecte.) Frequency: h Monthly (If frequency is not selecte, it will be monthly.) h Quarterly h Semi-Annually h Annually Date of Withrawal: h 5th h 10th h 20th (If ate is not selecte it will be the 20 th.) Payment Deposit Information (If no payment option is complete, a check will be maile to the client s aress of recor.) Select One: h Checking - Must attach a copy of a voie check h Savings - Must attach the following information on the Financial Institution s letterhea: Routing Number Account Number Accountholer s Name h Brokerage Account - Must attach the following information on the Financial Institution s letterhea: Routing Number Account Number Accountholer s Name Page 6 of 10

7 Tax Withholing Section Tax withholing election will remain in effect unless Lincoln is notifie of a change. You may change your election at any time. If you opt out of tax withholing, you are still liable for applicable taxes on your istribution. You may also incur penalties uner the estimate tax payment rules if your withholing an estimate tax payments are not sufficient. You may wish to iscuss your withholing election with a qualifie tax aviser. If tax information is not provie, feeral an applicable state taxes will be withhel. h Select to withhol the minimal Feeral tax an minimal State tax (if applicable). Option 1: Feeral tax withholing for payout options 1, 2, 4 an 5. h I elect to have no feeral income tax withhel. h I elect to have % feeral income tax withhel. (Minimum of 10%) Option 2: Feeral tax withholing for i4life Payments only h Do not withhol feeral income. h Withhol feeral income tax base on the following exemptions: h A. Single with allowances (if left blank, efault will be marrie plus 3 allowances) h B. Marrie with allowances (if left blank, efault will be marrie plus 3 allowances) h C. Amount to be withhel in aition to specifie exemptions $ State Tax Withholing Options Option 1: All States Except CA an VT If feeral income tax is withhel, state income tax may be withhel epening on your state of resience. AK, AZ, FL, HI, NV, NH, RI, SD, TN, TX, WA, WY: No state income tax. DC, IA, ME, MA, NE, OK, VA: If feeral income tax is withhel, manatory state tax withholing is require. AR, OR: If feeral tax is withhel, you may opt out of state withholing. DE, KS: If subject to manatory feeral tax withholing, then state income tax is also require. Otherwise, you may opt out of state income tax withholing. MI: Must elect or opt out of state income tax withholing on form MI W-4P. NC: Manatory withholing will apply unless form NC-4P is submitte to opt out or withhol more than the minimum. All Other States: Tax withholing is voluntary. State of resience: h Voluntary tax amount: $ OR % h OPT OUT (Do not withhol state income tax) Option 2: CA an VT CA: If feeral tax is withhel, you may opt out of state withholing. If state tax withholing is electe, the minimum withholing must equal 10% or more of the feeral withholing amount. VT: If feeral income tax is withhel, manatory state tax withholing is require an must equal 24% or more of the feeral withholing amount. State of resience: h % this will be base on the taxable portion of the gross istribution h OPT OUT (Do not withhol state income tax) Page 7 of 10

8 Election of Beneficiary Section (If Claimant oes not elect a Beneficiary payment will efault to the Claimant s estate.) Primary (you must have at least one primary beneficiary) Please use whole percentages. Itemize percentages must equal 100% Name: Relationship: Percentage: Social Security/Tax ID Number: Date of Birth: Gener: h Male h Female Aress: City: State: ZIP: Telephone Number: Primary Contingent Name: Relationship: Percentage: Social Security/Tax ID Number: Date of Birth: Gener: h Male h Female Aress: City: State: ZIP: Telephone Number: Primary Contingent Name: Relationship: Percentage: Social Security/Tax ID Number: Date of Birth: Gener: h Male h Female Aress: City: State: ZIP: Telephone Number: Primary Contingent Name: Relationship: Percentage: Social Security/Tax ID Number: Date of Birth: Gener: h Male h Female Aress: City: State: ZIP: Telephone Number: If esignating a trust as beneficiary, complete the following: Primary Contingent Name: Percentage: Trustee s Name: Date of Trust: Telephone Number: Social Security/ Tax ID Number: Aress: City: State: ZIP: If aitional beneficiaries are to be name, please check here h an attach on a separate sheet which must be signe an ate by you. You may also make aitional copies of this page if necessary. Page 8 of 10

9 Telephone/Internet Authorization (check box if this option is not esire.) For your convenience, the Company will accept certain account changes via telephone or the internet. You may opt out by checking the box below. This telephone/internet authorization remains in effect until written cancellation signe by the Contract Owner(s) is receive by the Company s Servicing Office. I/We hereby authorize an irect the Company to accept instructions via telephone or the internet from any person incluing my/ our registere representative who can furnish proper ientification to exchange units from sub account to sub account, change the allocation of future investments, an/or clarify any unclear or missing aministrative information containe on the application at the time of issue. I/We agree to hol harmless an inemnify the Company an its affiliates an any mutual fun manage by such affiliates an their irectors, trustees, officers, employees an agents for any losses arising from such instructions. If you DO NOT want Telephone/Internet Authorization check this box h Signature The Internal Revenue Service oes not require your consent to any provision of this ocument other than the certification require to avoi backup withholing. You unerstan that by furnishing a claim form, the Company oes not acknowlege that there is a contract in force or that you are the esignate beneficiary. If necessary, the Company may ask for more information to confirm this claim. By signing below, you certify that you: Authorize the irect eposit of the payment into the account ientifie on this form. This authorization requires the financial institution to be a member of the National Automate Clearing House Association (NACHA). Lincoln is also authorize to initiate corrections, if necessary, to any amounts creite or ebite to your account in error. You also agree to hol Lincoln harmless for the ate funs are actually creite to your account by your financial institution. This authorization will remain in effect until your funs are eplete or you notify Lincoln of change in sufficient time to act. Unerstan an assume full responsibility for meeting the Internal Revenue Coe requirements to qualify for this istribution. You further agree to hol Lincoln harmless for any averse tax ramifications that may arise base on the information provie on this form. Frau Warning for New York Resients: Any person who knowingly an with intent to efrau any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleaing, information concerning any fact material thereto, commits a frauulent insurance act, which is a crime, an shall also be subject to a civil penalty not to excee five thousan ollars an the state value of the claim for each such violation. This form is not complete until it is signe by the Claimant Claimant s Full Legal Name (Please Type or Print) Always require to be complete Claimant s Signature Date Page 9 of 10

10 Frau Warnings Warning Any person who knowingly an with intent to injure, efrau or eceive any insurance company or other person files a statement of claim containing any false, incomplete or misleaing information or conceals, for the purpose of misleaing, information concerning any fact material to the claim, commits a frauulent insurance act, which may be a crime, an in certain states a felony. Penalties may inclue imprisonment, fines, enial of insurance an civil amages. These states require the following frau warnings: California (For your protection, California law requires this to appear.) Any person who knowingly presents false or frauulent claim for the payment of a loss is guilty of a crime an may be subject to fines an confinement in state prison. Colorao It is unlawful to knowingly provie false, incomplete, or misleaing facts or information to an insurance company for the purpose of efrauing or attempting to efrau the company. Penalties may inclue imprisonment, fines, enial of insurance, an civil amages. Any insurance company or agent of an insurance company who knowingly provies false, incomplete, or misleaing facts or information to a policyholer or claimant for the purpose of efrauing or attempting to efrau the policyholer or claimant with regar to a settlement or awar payable from insurance procees shall be reporte to the Colorao ivision of insurance within the epartment of regulatory agencies. District of Columbia: WARNING: It is a crime to provie false or misleaing information to an insurer for the purpose of efrauing the insurer or any other person. Penalties inclue imprisonment an/or fines. In aition, an insurer may eny insurance benefits, if false information materially relate to a claim was provie by the applicant. Kentucky Any person who knowingly an with intent to efrau any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleaing, information concerning any fact material thereto commits a frauulent insurance act, which is a crime. Minnesota A person who files a claim with intent to efrau or helps commit a frau against an insurer is guilty of a crime. New Hampshire Any person who, with a purpose to injure, efraus or eceives any insurance company, files a statement of claim containing any false, incomplete or misleaing information is subject to prosecution an punishment for insurance frau, as provie in N.H. Rev. Stat. Ann. Subsection 638:20. New Jersey Any person who knowingly files a statement of claim containing false or misleaing information is subject to criminal an civil penalties. Pennsylvania Any person who knowingly an with intent to efrau any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleaing, information concerning any fact material thereto commits a frauulent insurance act, which is a crime an subjects such person to criminal an civil penalties. Puerto Rico Any person who knowingly an with the intention of efrauing presents false information in an insurance application, or presents, helps, or causes the presentation of a frauulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same amage or loss, shall incur a felony an, upon conviction, shall be sanctione for each violation with the penalty of a fine of not less than five thousan ($5,000) ollars an not more than ten thousan ($10,000) ollars, or a fixe term of imprisonment for three (3) years, or both penalties. Shoul aggravating circumstances are present, the penalty thus establishe may be increase to a maximum of five (5) years, if extenuating circumstances are present, it may be reuce to a minimum of two (2) years. Page 10 of 10