Lincoln TermAccel Application - Insurance By Heroes

Step 1 of 5 - Proposed Insured Information

20%

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Phone Type(Required)

Social Security Number(Required)

Required by the carrier to process your application.

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Do you have a valid Driver's License?(Required)

Yes

Driver's License Issue State(Required)

Driver's License Number(Required)

Will you (the insured) also be the owner of this policy?(Required)

Yes

Policy owner information(Required)

Owner's name, relationship to you, and address.

Birthplace(Required)

State of Birth(Required)

Country of Birth(Required)

Occupation / Industry(Required)

Are you a US Citizen?(Required)

Yes

Are you an active duty service member of the U.S. Armed Forces (including National Guard and Reserve)?(Required)

Yes

Do you (and the policy owner) read and understand the English language?(Required)

Yes

Are you using income from your spouse/domestic partner to justify the coverage applied for?(Required)

Yes

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

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

Have you ever had any life or health insurance declined, postponed, or offered other than as applied for?(Required)

Yes

Do you have any life insurance or annuities in-force?(Required)

Yes

Existing Policy — Company(Required)

Existing Policy — Policy Number

Existing Policy — Face Amount(Required)

Existing Policy — Issue Date

MM slash DD slash YYYY

Existing Policy — Policy Type

Existing Policy — Policy Purpose

Are you replacing or terminating this policy?(Required)

Yes

Will this policy be used as a source of funding?(Required)

Yes

Please list any optional benefits on the existing policy

Additional existing policies

If 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

Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract?(Required)

Yes

Purpose of Insurance(Required)

Please Specify(Required)

Purpose — please describe

Who will pay the premiums (Premium Payor)?(Required)

Premium payment source(Required)

If "Other" payor or source, please describe

Primary Beneficiary

Full Name(Required)

Relationship(Required)

Beneficiary Date of Birth

MM slash DD slash YYYY

Share %

Please enter a number from 1 to 100.

Additional primary beneficiaries

Name, relationship, date of birth, and share % for each. Shares must total 100%.

Contingent beneficiaries (optional)

Name, relationship, date of birth, and share % for each.