Absolute Assignment of Group Life Insurance Form - Lincoln ...

ABSOLUTE ASSIGNMENT OF GROUP LIFE INSURANCEA. Group Life Insurance Plan (Plan): ___________________________________________________________________________(Print Name of Employer)Insured’s Name: _____________________________________________________Insured’s SSN: ___________________Address: ________________________________________________________________________________________________Street, City, State ZipI hereby assign any and all rights I have in the coverages provided under the Plan described above. Such rights include, but are not limitedto, any right of conversion for such benefits, the right to make any requisite contributions under said Plan, the right to change the beneficiaryand the right to elect any available settlement option to:_______________________________________________________________________________________________________(Print Name of Assignee)_______________________________________________________________________________________________________AddressThis assignment relates to my rights under any insurance policy that may provide insurance coverage under the Plan. I have read theexplanations and instructions set forth on the reverse side of this form. I agree that neither the Employer nor Lincoln Financial Group (or theiragents, representatives, or employees) assume responsibility for the validity or sufficiency of this assignment. I further agree that thisassignment shall take effect on the date it is recorded by Lincoln Financial Group.Executed this date of ____________________________ _________________________________________________(Month, Day, Year)Signature of AssignorDesignation of BeneficiaryB. Effective the date of this assignment, the above assignor hereby revokes any previous designation pertaining to the Plan. Ihereby designate the following as beneficiaries under this Plan:Name of Primary Beneficiary:_______________________________________________________________________________Relationship to Insured: ___________________________________________________________________________________Name of Contingent Beneficiary: ____________________________________________________________________________Relationship to Insured: ___________________________________________________________________________________Spouse Waiver for Assignment and Beneficiary Designation of Group Life BenefitsC. Please read the following section carefully. The spouse of the assignor should sign below IF the assignor is making anassignment or beneficiary designation to a person other than his/her spouse AND the assignor is a resident of one of thefollowing Community Property states: AZ, CA, ID, LA, NV, NM, PR, TX, WA, WI.I, spouse of the assignor, hereby consent to this assignment and beneficiary designation and waive and release any and all communityproperty rights in and to the subject matter of the assignment/beneficiary designation and to any employee contributions thereto, now andhereafter made from community funds._____________________________________________________Signature of Spouse_____________________________________________________Date (Month, Day, Year)______________________________________________Name of Spouse - Please Print______________________________________________Notary PublicSubscribed and sworn before me this ______________ day of ___________________________, __________My commission expires: _________________________To be completed by the EmployerSignature: _______________________________________________Title: ___________________________________________________Date: ___________________________________________________The Lincoln National Life Insurance Company, PO Box 2649, Omaha, NE 68103-2649toll free (800) 423-2765www.LincolnFinancial.comTo be completed by Lincoln Financial GroupLincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.Page 1 of 2GLA-01859 7/08(SEAL)Signature: _____________________________________Title: __________________________________________Date: __________________________________________

INSTRUCTIONS(Absolute Assignment)An assignment is a voluntary act, the legal effect of which depends upon the expressed purpose and intent ofthe assignor. This assignment form is for the convenience of certificate holders. It can be used properly onlyif it is read and considered by the assignor, in the light of his or her special situation. The Lincoln National LifeInsurance Company and the policyholder can assume no responsibility for an assignment, because they haveno way of knowing the assignor’s purpose and intent. Therefore, the assignor is urged to consult an attorneybefore completing this form.The following are some specific explanations and instructions concerning this form and its use:1. NATURE OF FORM. This is an absolute assignment form. It should not be used in connection with collateralor viatical assignments.2. BENEFICIARY DESIGNATION. The assignor may change the beneficiary on this form before the assignmentis recorded, provided the previous designation is revocable. Once the assignment has been recorded, theassignor can no longer change the beneficiary. After the assignment is recorded, only the assignee canchange the beneficiary, and then only if the previous designation is revocable.3. CONVERSION. Once the assignment has been recorded, the assignor cannot subsequently effect aconversion. After the assignment is recorded, only the assignee can apply for a conversion, and then onlywhen the conversion provision would have been available to the assignor, in the absence of this assignment.4. COMMUNITY PROPERTY. In some states community property is an established form of ownership asbetween spouses. Where applicable, the consequences of that form of ownership must be considered inmaking an assignment and therefore, we recommend that Section C of the form be completed prior tosubmitting this assignment.5. PROCEDURE.a. The signature of the assignor must be in ink and should appear exactly as the name is given in thecertificate. Exception: If the assignor is a woman and has changed her name due to marriage ordivorce, the certificate was issued, her current surname should be added to her name as given inthe certificate.b. The date on which the assignor signs must be included in the space provided.c. The Employer must sign off on this assignment before the form can be validated by The LincolnNational Life Insurance Company.d. Complete this form in triplicate. Send all three copies to the address shown on the form. Thisassignment is not effective until it is recorded by The Lincoln National Life Insurance Company.e. If the assignor is naming a Trust as the assignee, please submit a copy of the Trust along with thisassignment.After The Lincoln National Life Insurance Company records this assignment, two copies will be returnedto the Employer, who should then:a. note the assignment on their records and retain one copy of the assignment; andb. inform the assignee of the assignment and release the other copy of the form for attachmentto the certificate.Page 2 of 2GLA-01859 7/08