Policy / Certificate Loan Agreement

Transcription

1 The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York First Penn-Pacific Life Insurance Company (as in your contract and herein the Company ) Life Client Solutions Contact Information Mail: PO Box 21008, Greensboro, NC Phone: Fax: CustServSupportTeam@LFG.com Policy / Certificate Loan Agreement General Information (Please type or print clearly.) This section must be completed. Policy/Certificate No.: Issued by (the Company): Insured Information Full Legal Name (First, Middle, Last): Insured s Mailing Address: City: State: Zip: Social Security Number: of Birth: Daytime Telephone Number: Address: Full Legal Name (First, Middle, Last): Owner s Mailing Address: City: State: Zip: Social Security Number/EIN*: of Birth/Trust**: Daytime Telephone Number: Address: *The submission of a completed IRS Form W-9 may be required. Employer Identification Number for Trusts or Entities **The date the trust was established Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 5

2 Payment Options Please select one of the following options below: h CHECK h ACH h Wire ($25.00 fee applies) h If the policy has multiple owners indicate here for the proceeds to be distributed to each owner per the percentages noted in the addendum. Total proceeds from jointly owned policies will be paid by check. If a request is made to wire funds or send funds through ACH to a bank account, a copy of a voided check must be submitted. Funds sent by wire are charged $25.00 and the amount of the wire is deducted from the net loan value. Income Tax Withholding Election - Substitute W-4 or W-4P Federal law requires tax be withheld from the taxable portion of certain life insurance payments, unless you request not to have tax withheld. The tax applies only to the taxable portion of the payment, not the entire payment, should this be considered taxable. Elect withholding or no withholding by checking the appropriate box below. Be sure to complete this form by signing it and filling in your Social Security number/tax Identification number. If you do not make a choice, or if you do not furnish us with your Social Security number/tax Identification number, we will withhold federal income tax in addition to any appropriate State Income tax from any taxable portion of your payment. Should you wish to know the taxable amount prior to making this election, please contact a Customer Care Representative at between the hours 8:00 a.m. 6:00 p.m. (Eastern Time), Monday through Friday. Even if you decide not to have federal/state tax withheld, you are still liable for payment of the income tax on the taxable portion of this payment. You may be subject to tax penalties under the Estimated Tax Payment Rules if your payment of estimated tax and withholding, if any, are not sufficient. This section must be completed. If no selection is made and your loan is considered taxable, taxes will be withheld. If a withholding election is made that is contrary to IRS or State requirements, then the IRS or State requirements will be applied. Check ONE BOX: h I do NOT want to have Federal Income Tax or State Income Tax withheld. h I DO want to have Federal Income Tax and State Income Tax (if state mandated) withheld. h I want to have Federal Income Tax, withhold h or h $ h I want to have State Income Tax, but not at the mandated rate, withhold h % or h $ State of Residency for tax purposes: (if different from the mailing address) Situs* of the Trust for tax purposes: (if different from the mailing address) (*Situs of the trust is the state to which the trust must file income tax) Note: If the Owner is a Trust, Corporation, Partnership, LLC, Life Settlement Company or other entity; a completed W-9 Request for Taxpayer Identification Number and Certification (Rev. August 2013) will be required. If not provided, the IRS mandates withholding on the taxable income, if any. By signing on the following page, you certify that the information provided is complete and accurate as shown. You also certify that you have read, understand and agree to the information provided. Under the penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (US resident alien). Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. A W-9 form is required if no Social Security number/tax Identification Number is on file or differs from our records. Page 2 of 5

3 Loan Request (Please check only one box) By signing below, you assign, transfer and set over to the Company, to the extent of any loan and accrued interest thereon, all of your rights, title and interest in the policy/certificate together with all money that may become payable as sole security for: h A loan in the amount of $ or the maximum loan value your policy/certificate will allow, if less than this amount. h The maximum loan available. Indexed Universal Life Accumulator policy loans may be taken as Fixed or Participating Loans. Check the appropriate box below to indicate your selection. If no selection is made, the loan will be taken as a Participating loan. h Fixed h Participating Please note: This option is product specific. Please refer to your policy before making a selection. Fund specific withdrawals are not available on policies beginning with the letter F. Loans on Variable Universal Life policies/certificates will be made in proportion to the assets in each subaccount and processed accordingly, unless otherwise specified below. If the Company is unable to comply with your fund specific request, the loan will be made in proportion to the assets in each subaccount. Subaccount Amount % of Loan Amount Total must equal 100% A check is made payable to the Policy/Certificate Owner and assignee or Irrevocable Beneficiary unless indicated below. This distribution is to be applied to policy number: as a: h Premium payment h Loan repayment Such payment shall to the extent thereof discharge the Company from all liability. Please Note: Loans reduce both the cash value and death benefit of the Policy/Certificate, and, if not repaid, could eventually lead to a premature lapse of the Policy/Certificate. Refer to your Policy s/certificate s loan provisions for additional information. If the Policy/Certificate is a modified endowment contract, your loan may be considered a taxable event. Should you wish to know the taxable amount prior to making this election, please contact a Customer Care Representative at between the hours 8:00 a.m. 6:00 p.m. (Eastern Time), Monday through Friday. Additionally, a loan may affect and/or forfeit guarantees as stated in the policy contract. Special Instructions: Page 3 of 5

4 Authorizations and Signatures I certify that the information provided on this form is complete and correct: Owner s Signature Owner s Signature** Assignee / Irrevocable Beneficiary Signature (if applicable) Assignee / Irrevocable Beneficiary Signature (if applicable) * Required for a corporation, partnership, or trust ** See addendum for multiple owner policies. Signature Requirements - Digital/Electronic signatures will not be accepted. Owner - Signature(s) Required - Individual(s)* - Policyowner(s) Corporation, Bank or Financial Institution - Signature of one officer with title, and a corporate resolution which names all officers authorized to sign on the behalf of the corporation; or two officer s signatures, with title, without corporate resolution. Conservator or POA - Signature of Conservator or POA with title. We require Letter of Conservatorship along with court order designating conservator/guardian or copy of the POA document to be on file. If POA is dated more than 3 years, we require an affidavit to accompany the request. Signature Example: John Doe, POA for Jane Doe. Trust - Signature of all trustee(s) with title along with the completed Certification of Trustee Powers form AN Partnership or LLC - We require one general/managing partner signature with title and a copy of the Partnership agreement for Partnerships OR one managing member s signature with title and a copy of the operating agreement for LLCs. Custodian/Minor - We require court order Letter of Guardianship or UGMA or UTMA paperwork. (If the custodian designation was completed on page 3, additional paperwork is not required.) Signed by an X - If signor is unable to sign and must sign with an X, we require signature be notarized. Stamped signatures - We will not knowingly accept a stamped signature. All other insterested parties - Contact customer service to verify signature(s) needed. Page 4 of 5

5 Addendum for Multiple Owner Policies (submit more pages as necessary) Full Legal Name (First, Middle, Last): Signature: : Owner s Mailing Address: City: State: Zip: Social Security Number / EIN*: Daytime Telephone Number: of Birth / TIN**: Address: Full Legal Name (First, Middle, Last): Signature: : Owner s Mailing Address: City: State: Zip: Social Security Number / EIN*: Daytime Telephone Number: of Birth / TIN**: Address: Full Legal Name (First, Middle, Last): Signature: : Owner s Mailing Address: City: State: Zip: Social Security Number / EIN*: Daytime Telephone Number: of Birth / TIN**: Address: * The submission of a completed IRS Form W-9 may be required. Employer Identification Number for Trusts or Entities ** The date the trust was established Page 5 of 5