Lincoln TermAccel Application Please complete this form to begin your Lincoln TermAccel term life application. Step 1 of 5 - Proposed Insured Information 20% Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Phone Type(Required)— Select —MobileHomeWorkSocial Security Number(Required)Required by the carrier to process your application.Date of Birth(Required) MM slash DD slash YYYY Gender(Required)— Select —MaleFemaleDo you have a valid Driver's License?(Required) Yes No Driver's License Issue State(Required)— Select —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDriver's License Number(Required)Will you (the insured) also be the owner of this policy?(Required) Yes No Policy owner information(Required)Owner's name, relationship to you, and address. Birthplace(Required)— Select —United StatesOther CountryState of Birth(Required)— Select —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCountry of Birth(Required)Occupation / Industry(Required)Are you a US Citizen?(Required) Yes No Are you an active duty service member of the U.S. Armed Forces (including National Guard and Reserve)?(Required) Yes No Do you (and the policy owner) read and understand the English language?(Required) Yes No Are you using income from your spouse/domestic partner to justify the coverage applied for?(Required) Yes No Spouse/Domestic Partner Income(Required)Life insurance in-force (plus applied for that will be placed)(Required)Total dollar amount of life insurance you already have in force, plus any applied for that you plan to keep. Enter 0 if none.Do you participate in aviation activities?(Required) Yes No If underwriting results in a higher premium, which do you prefer?(Required) Pay the extra premium for coverage if death benefit results from a covered aviation activity. Aviation Exclusion Rider (not available in all states, and subject to underwriter discretion). Is there an application for life, accident, or sickness insurance now pending or contemplated for you with this or any other company?(Required) Yes No Have you ever had any life or health insurance declined, postponed, or offered other than as applied for?(Required) Yes No Do you have any life insurance or annuities in-force?(Required) Yes No Existing Policy — Company(Required)Existing Policy — Policy NumberExisting Policy — Face Amount(Required)Existing Policy — Issue Date MM slash DD slash YYYY Existing Policy — Policy Type— Select —Term LifeWhole LifeUniversal LifeVariable LifeGroup Life (through work)AnnuityOtherExisting Policy — Policy Purpose— Select —PersonalBusinessAre you replacing or terminating this policy?(Required) Yes No Will this policy be used as a source of funding?(Required) Yes No Please list any optional benefits on the existing policyAdditional existing policiesIf you have more than one existing policy: company, policy number, face amount, issue date, and type for each.Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract?(Required) Yes No Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?(Required) Yes No Purpose of Insurance(Required)— Select —PersonalBusinessPlease Specify(Required)— Select —Charitable GiftEstate Planning/Wealth TransferFamily or Mortgage Protection/Income ReplacementOtherPurpose — please describeWho will pay the premiums (Premium Payor)?(Required)— Select —InsuredOwnerOtherPremium payment source(Required)— Select —IncomeSalarySavingInvestments1035 ExchangeOtherIf "Other" payor or source, please describe Primary BeneficiaryFull Name(Required)Relationship(Required)— Select —SpouseDomestic PartnerFiancé(e)ChildParentSiblingBusiness PartnerTrustCharityEstateOtherBeneficiary Date of Birth MM slash DD slash YYYY Share %Please enter a number from 1 to 100.Additional primary beneficiariesName, relationship, date of birth, and share % for each. Shares must total 100%.Contingent beneficiaries (optional)Name, relationship, date of birth, and share % for each.
