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LINCOLN FINANCIAL CLAIM FORMS




If you have lost the claims form you received in the mail, you can download another copy here.

If you are beginning the claims process, please walk through our steps to filing a claim and start by submitting an online claim notification.

Need help with your claim or choosing which form to download?
For help with Life or Long-Term Care Claims, call 800 487-1485 and select option 4.
For help with Annuity Claims, call 800 454-6265 and select option 3.

Life insurance claim forms

Claimant's Statement
Complete this form if you are the beneficiary of a life insurance policy.

View Claimant's Statement checklist

Life Distinctive Payee Arrangement
This form is to be completed if the beneficiary is a Trust, Corporation, Partnership or Guardian.

Foreign Death Questionnaire
Use this form if the death of the insured occurred in a country other than the United States.

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Long-Term Care claim forms

Long-term Care Affidavit
This form is to be completed by the Power of Attorney appointee when the Power of Attorney document is more than three years old.

Care Provider Assessment
This form is to be completed by all providers who provide or have provided care services to the insured during the time benefits are requested.

Authorization for Release of Health-Related Information
(HIPAA compliant) Use this form to authorize the release of health-related information about the insured.

Home Health Care Provider Service Record
Use this form to document the dates of services provided by Home Health Care Providers and the costs incurred.

Insured's Statement of Loss
Complete this form to verify information regarding why benefits are being requested.

Assignment of Benefits
Use this form to authorize benefits to be paid directly to a care facility.

Medical Assessment — Plan of Care
This form is to be completed by the physician who is certifying that the insured requires care services.

Claim Assessment Plan of Care Review
Physicians should use this form if there has been a change in level of care on an approved claim.

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Annuity claim forms

Claim Supplement for Active i4LIFE Policies
Beneficiaries who wish to continue i4Life® payments on a policy that currently has an existing i4Life payment being distributed should complete this form.

Annuity Distinctive Payee Arrangements
This form is to be completed if the beneficiary is a Trust, Corporation, Partnership or Guardian.

Nonqualified Annuity Claimant's Statement
This form is to be completed by beneficiaries of nonqualified annuities.

Qualified Annuity Claimant's Statement
This form is to be completed by beneficiaries of qualified annuities.

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Hello future.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and insurance
company affiliates, including The Lincoln National Life Insurance Company, Fort Wayne, IN,
and in New York, Lincoln Life & Annuity Company of New York, Syracuse, NY. Variable products
distributed by broker/dealer-affiliate Lincoln Financial Distributors, Inc., Radnor, PA. Securities
and investment advisory services offered through other affiliates. Explore Lincoln.



LCN-2008274