Transcription of The Lincoln National Life Insurance Company
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The Lincoln National Life Insurance Company
Page 1 of 8 GLC11738 STD 1/18 Lincoln Financial Group is the marketing name for Lincoln National Corporation and its Term Disability Claim Form Statement Of Employee1. Your Information / / Full Name (First)( )(Last Name)Social Security NumberDate of BirthStreet AddressPhone NumberCityStateZip CodeEmail Addressh Male h Female2. Your EmployerEmployer NameGroup IDJob TitlePolicy NumberBilling Location3. Reason for inability to workDescription of Sickness, Injury or Pregnancy / / Date Last WorkedInjury work related? h Yes h NoAmount $Date BeganDate Will TerminateDateApplied ForSocial Security_____ / / / / / / Workers Comp_____ / / / / / / Salary Continuance_____ / / / / / / State Disability
The Lincoln National Life Insurance Company is not responsible for charges incurred due to completion of this form. The patient is responsible for any charges associated with form completion. The Lincoln National Life Insurance Company PO Box 2609, Omaha, NE 68103-2609 Toll Free (800) 423-2765 Fax (877) 843-3950 www.LincolnFinancial.com
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