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Lincoln
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Financial Group
Enrollment/Change Request &
Salary Reduction Agreement
The Lincoln National Life Insurance Company Variable Annuity
XX Xxx 0000
Xxxxxxxx XX 00000-0000
Phone 000 000-0000
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Participant Employee's name Soc. Sec. no.
Information ----------------------------------------------------------------------------------------------------------
Address
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* Proof required, City, State, ZIP
refer to the back ----------------------------------------------------------------------------------------------------------
of this form. [ ] Male [ ] Female Marital status Daytime phone
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Your personal Date of birth Date of hire/rehire Evening phone
investment elections ----------------------------------------------------------------------------------------------------------
should be consistent Employer's name
with your primary ----------------------------------------------------------------------------------------------------------
investment GP/ER ID number Group Annuity Contract nos.
objectives. ----------------------------------------------------------------------------------------------------------
[ ] New enrollment Change of: [ ] Name* [ ] Beneficiary
Refer to your [ ] Allocation election [ ] Address/phone [ ] Salary Reduction
variable annuity Select one primary investment objective for your retirement plan.
brochure for [ ] Stability of Principal [ ] Growth & Income [ ] Growth [ ] Aggressive Growth
investment Number of dependents Occupation
objective ---------------------------- ---------------------------------------------
information. Total family income $ Estimated net worth $
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Salary Reduction Check with your payroll department to determine which option they use per pay period.
Information Salary reduction $ or % of pay Date of reduction
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Percentages must be You may select up to ten investment funds.
in whole numbers % Asset Manager % Guaranteed % Mid Cap Value
only and must total ---------- ---------- ----------
100%. % Balanced % Index % Small Cap
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% Equity Income % International % Small Cap Growth
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% Global Growth % Mid Cap Growth I % Social Awareness
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% Growth I
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Beneficiary Complete the following information for each beneficiary. (You must have at least one primary.)
Designation Primary's name Soc. Sec. no.
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Percentages must be Relationship Date of birth Percentage
in whole numbers ----------------------------------------------------------------------------------------------------------
only. The total of Address
percentages for ----------------------------------------------------------------------------------------------------------
primary and City, State, ZIP
contingent ----------------------------------------------------------------------------------------------------------
beneficiaries must [ ] Primary [ ] Contingent
each equal 100%. Name Soc. Sec. no.
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Relationship Date of birth Percentage
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Address
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City, State, ZIP
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Authorization and By signing below, you certify that you have read, understand and agree to the terms of the Salary
Signatures Reduction Information and Agreement sections on this form and have received an Active Life Certificate.
The signature of the employer authorized representative certifies that he/she also agrees to the Salary
Reduction Information section.
Participant's signature Date
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Employer authorized
representative's signature Date
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Plan administrator's
signature (if ERISA) Date
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Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. continued on back
Form L1282-94 1/00 Enrollment
White copy - TDA Client Services Yellow copy - Payroll Pink copy - Broker Goldenrod copy - Participant
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Agreement
You agree that:
Variable Annuity Information
. You have read the prospectus for the insurer's variable annuity and the
underlying funds. You also understand that the underlying funds supporting
the insurer's variable annuity are not public funds, but are available only
through insurance contracts.
. The investment objectives and policies are stated in each of the underlying
fund's prospectus.
. You will review your investment selections on a regular basis as your
lifestyle or investment goals may change as you near retirement. As part of
this review you should read current fund prospectuses and financial reports.
You may contact Lincoln Life at any time to receive up-to-date information
about your variable annuity.
. Withdrawals are restricted to the requirements of Section 403(b) of the
Internal Revenue Code as described in the insurer's current variable annuity
prospectus. Withdrawals must also be in accordance with any restrictions
described in your tax deferred annuity plan sponsored by your employer.
. If contributions are received by the insurer without complete and accurate
information, your contributions will be allocated to the Pending Allocation
Account. Once this information is received, the insurer will allocate your
contributions as indicated on the form. After the third monthly notice, if
the insurer has not received this information, the account value will be
returned to the contractholder.
. If you transfer assets to the insurer without a transfer form indicating an
allocation split, the insurer will deposit these assets based on the most
recent investment elections on file.
. Confirmations will be generated once the insurer receives complete enrollment
information. Please review the confirmation carefully and notify the insurer
immediately if any changes are desired. The insurer may elect to send any
confirmations of transactions relating to your account directly to your
employer.
. Any changes to your name and/or beneficiary designations must be in writing.
Proof is required for name changes. Sumbit a copy of a marriage license,
divorce decree, or other court document.
. Returns on the variable accounts are based upon the investment experience of
the insurer's separate account. These amounts will fluctuate and are not
guaranteed as to the dollar amount.
Salary Reduction
. The employer shall reduce your salary by the amount indicated per pay period.
The employer shall forward this amount to the insurer as contributions toward
a 403(b) annuity.
. Payroll reductions will begin on the date indicated. Any change in allocation
election will be effective with the next contribution after receiving this
form in the Portland, Maine office.
. This agreement is legally binding and irrevocable regarding the amounts
already deferred by both you and the employer while employment continues for
amounts earned while it is in effect.
. This agreement will apply only to amounts earned after this agreement becomes
effective. It will not apply to any amounts earned after it is terminated.
Beneficiary Designation
. If additional space is needed, attach a separate sheet.
. If you are married or will be married and if your tax deferred annuity plan
provides, the primary beneficiary will be your spouse unless he/she completes
and signs a waiver form provided by your employer.
. If your plan is subject to ERISA, your beneficiary designation must be in
compliance with all provisions of the Retirement Equity Act of 1984 and the
applicable tax deferred annuity plan, which requires a plan administrator's
signature.
. Your beneficiary designation on this form supersedes any prior designation
made in regards to the coverage under this contract.
. If no beneficiary is selected, or if no beneficiary survives you, all death
benefits will be paid according to the contract and any applicable tax
deferred annuity plan.
. Your primary beneficiary will be entitled to the entire value of the account.
Multiple surviving primary beneficiaries will be entitled to equal portions
of the account unless specified otherwise.
. Your contingent beneficiary will be entitled to the entire value of the
account if no primary beneficiary is living. Multiple surviving contingent
beneficiaries will be entitled to equal portions of the account unless
specified otherwise.
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Customer Service
If you have any questions, please contact Lincoln Life at 000 000-0000.
Form L1282-94 1/00
