Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 14 GLC-01252

GROUP lOnG-teRm disability claim(Please see FRaUd nOtices attached)

EMPLOYER GROUPPOLICYNO.

______________________________________________________________________ _____________________________

emPlOyeR -formcompletioninformation

nOtice OF claim - instructions

A. completetheemployer’s portion in fullandreturn this portiontoaddressaboveorfaxtothenumberabove

include d Copyofenrollmentcard(ifemployeecontributestopremium)

d Copyofapprovedmedicalevidenceofinsurabilityifrequiredattimeofenrollment

d IfWorkers’Compensationclaimfiled,includecopyofFirstReportofAccidentandthedecision

B. Give remaining part of form to claimant for completion

The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com

Page 2 of 14 GLC-01252

long-term disability claim employer’s statement

to be completed by the employer

Thisclaimisfor(Employee’sNameandAddress) SocialSecurityNumber DateofBirth

a. information about the employer

Company’sName GroupPolicyNumber ClassNumber

Address(Street,City,State,Zip) Telephone:Fax:

Nameandaddressofdivisionwhereemployeeworks(ifdifferentfromabove) Telephone:Fax:

b. information about the employeeDateemployeewashired(Month,Day,Year)

Dateemployeebecameinsuredunderthisplan?Dateemployeebecameinsuredunderpriorplan?

Whatwastheemployee’sregularlyscheduledworkweek?________hoursperweek________hoursperday

c. information needed for withholding and reporting taxes

Doesemployeecontributepost-taxdollarstowardthepremium? Yes NoIfyes,whatpercentispaidbytheemployee?________%if you leave this section blank, we will assume it is 100% employer contribution and calculate Fica taxes accordingly.

d. information about the claim

Werethereanychangestotheemployee’sjobresponsibilitiesduetothedisablingconditionbeforetheemployeebecamefullydisabled?YesNoIfyes,whatwerethechangesandwhenweretheymade?

Whatwastheemployee’spermanentjobonhisorherlastdayatwork? Howlonghadtheemployeebeeninthisjob?

Lastdayemployeeactuallyworked(Month,Day,Year)

Onthatday,didtheemployeeworkafullday?YesNoIfno,howmanyhourswereworked?

Whydidemployeestopworking? Istheemployee’sconditionworkrelated?YesNo

HasaclaimbeenfiledwithWorkers’Compensation?YesNoIfyes,sendinitialreportofillnessorinjuryandawardnotice.Name,addressandtelephonenumberofyourcompensationcarrier

Name,addressandtelephonenumberofyourmedicalinsurancecarrier

e. information about your pension plan(donotcompleteformaternityclaim) (For Lincoln Financial to complete)Doyouhaveapensionplan?YesNo

Ifyes,whattype? Definedbenefit 401(k) Other:(specify) Definedcontribution Profitsharing

Istheemployeeeligibleforyourpensionplan?YesNoIfno,why?

Ifeligible,doestheemployeeparticipate?YesNoIfno,why?

Iftheemployeeisparticipating,whenisheorsheeligibleforbenefitsundertheplan?(Month,Day,Year)

nOte: if any portion of this pension benefit is attributable to the employee’s contribution, please provide details including the percentage of his/her contribution to the total contribution. this should include a copy of the contract.

F. information about your rehire or return-to-work policies

Doesyourcompanyhavearehireorreturn-to-workpolicyfordisabledemployees?YesNo

Whatisthenameandtitleofthemanagerweshouldcontactifweidentifyarehabilitationorreturn-to-workoption?

G. information about the employee’s salary

Theemployee(Checkallthatapply)ispaidhourly(whatisthehourlyrate?)$________________________issalariedreceivescommissionsreceivesbonuses

Willemployeefilefordisabilitybenefitsprovidedbyanyemployer/employeelabormanagement,statedisabilityorunionwelfareplan?YesNoIfyes,whatistheweeklyamount?$_____________-______Whendobenefitsbegin?_________________End?_________________

Isthisemployeeeligibleforsalarycontinuation?YesNoIfyes,whatistheweeklyamount?$___________________Whendobenefitsbegin?_________________End?_________________

(Continuedonnextpage)

Page 3 of 14 GLC-01252

Reporting the employee’s basic monthly earnings

Findthedefinitionofbasicmonthlyearningsthatmatchesyourcontractforthisemployeeandfollowtheinstructionsgiven.

definitions of basic monthly earnings

a. salaryonly(nocommissions,bonuses,etc.),completequestion1belowb. previousyear’sW-2form,completequestion5below(attachW-2)c. soleproprietor,completequestion8belowd. previousyear’sK-1form,completequestion6below(attachK-1)

e. salaryandcommissions,completequestions1and3belowf. salary,commissionsandbonuses,completequestions1,3and4belowg. salaryanddeferredcompensation,completequestions1and2belowh. salary,deferredcompensationandcommissions,completequestions1,2and3belowi. salary,deferredcompensation,commissionsandbonuses,completequestions1,2,3and4belowj. salaryandK-1earnings,completequestions1and6below

k. W-2withdeferredcompensation,completequestions2and5belowl. partnershipagreement,completequestion7belowm. teacher’scontract,completequestion1belown. anyotherdefinition,completequestion9below

1) Onthelastdayemployeeworked,whatwashisorherbasicmonthlysalary?(Divideannualsalaryby12ormultiplyweeklysalaryby52anddivideby12.Teachersdivideannualsalaryby12) 1_____________________

2) Onthelastdaytheemployeeworked,whatwashisorhermonthlypre-taxcontributiontoyourdeferredcompensationplan? 2_____________________

3) Howmuchhadtheemployeereceivedincommissionsinthe12months(ortheperiodofemploymentiflessthan12months)immediatelyprecedingthelastdayworked?$____________________.Dividethisnumberby 3_____________________12,orthelengthofemploymentiflessthan12months,tofindtheaveragemonthlycommissions.

4) Howmuchhadtheemployeereceivedinbonusesinthe12months(ortheperiodofemploymentiflessthan12months)immediatelyprecedingthelastdayworked?$____________________.Dividethisnumberby12, 4_____________________orthelengthofemploymentiflessthan12months,tofindtheaveragemonthlybonuses.

5) Whatweretheemployee’searningsasshownontheW-2formoftheyearimmediatelyprecedingthedisability? 5_____________________

6) Whatweretheemployee’searningsasshownontheK-1formoftheyearimmediatelyprecedingthedisability? 6_____________________

7) Asofthelastdaytheemployeeworked,whatwerethebudgetedannualearningsasdeterminedbythewrittenpartnershipagreementineffect?(Donotincludedividends,interestorreturnofcapital)$____________________. 7_____________________

8) Asofthelastdaytheemployeeworked,whatwasthesoleproprietor’sannualnetprofit(1040ScheduleCgrossincomeminustotaldeductionsminusdepreciation)averagedoverthe3yearsimmediatelyprecedingthedisabilityortheperiodofsoleproprietorshipiflessthan3years? 8_____________________

9) Fordefinitionsotherthanthoseabove,calculatethemonthlyearningsastheyaredefinedinyourcontract.Ifearningsarebasedonsalaryasexpressedonaparticulardocument,sendusacopyofthedocument. 9_____________________

H. Required attachments and signature

Iftheemployeecontributestothepremiums,attachacopyoftheenrollmentform.

IfsalaryisbasedonaW-2,K-1,1099,orasimilardocument,attachacopyofthedocument.

Ifyouhavemedicalinformationfromtheemployee’sfilerelatingtothisdisability,pleaseattachcopies.

Ifaworkers’compensationclaimisfiled,sendinitialreportofinjuryorillnessandawardnotice.

Nameofpersoncompletingthisform(Ifthisclaimisapprovedfordisabilitybenefits,thebenefitcheckwillbesenttotheemployeewithacarboncopytoyou.)

X _____________________________________________________________ _________________________________________ ____________________Signature Title Date

Page 4 of 14 GLC-01252

long-term disability claim Job analysis

to be completed by the employee’s supervisor

this claim is for (employee’s name)

Employee’sSocialSecurityNumber DateofDisability(Month,Day,Year)

a. General information about the employee’s job

JobTitle Minimumeducationortrainingrequired

Doestheemployeeperformsupervisoryfunctions?YesNoIfyes,howmanypeoplearesupervised?___________________________Describejobduties.

Checktheitemsbelowthatrelatetotheemployee’sjob.Usethesedefinitionsforthefrequencyofoccurrence:Occasionallymeansthepersondoestheactivityupto33%ofthetime.Frequentlymeansthepersondoestheactivity34%to66%ofthetime.continuouslymeansthepersondoestheactivity67%to100%ofthetime.

Occasionally Frequently continuouslyRelatetoothers

Writtenandverbalcommunication

Reasoning,mathandlanguage

Makesindependentjudgments

Whichofthefollowingdescribetheemployee’sworkingenvironment?Checkallthatapply.Unprotectedheights Changesintemperatureorhumidity Exposuretodust,fumesandgasesBeingnearmovingmachinery Drivingautomotiveequipment OtherhazardsIstheemployeerequiredtotravel?YesNoIfyes,completethefollowinginformation:Howdoestheemployeetravel?(Automobile,plane,train,etc.)Wheredoestheemployeetravel? Whatpercentofthetimedoestheemployeetravel?

b. information about the physical aspects of the employee’s jobChecktheitemsbelowthatrelatetotheemployee’sjobandcompletetheinformationrequested.Usethesedefinitionsforthefrequencyofoccurrence:

Occasionallymeansthepersondoestheactivityupto33%ofthetime.Frequentlymeansthepersondoestheactivity34%to66%ofthetime.continuouslymeansthepersondoestheactivity67%to100%ofthetime.

activity Frequency of OccurrenceOccasionally Frequently continuously

Standing

Walking

Sitting

Balancing

Stooping

Kneeling

Crouching

Crawling

Reaching/workingoverhead

Climbing:

Stairs

Numberofstairs:___________ Ladders describe activity Weight

HeightofLadder:___________

Pushing ___________________________________ ___________lbs.

Pulling ___________________________________ ___________lbs.

Lifting/carrying ___________________________________ ___________lbs.

(Continuedonnextpage)

Page 5 of 14 GLC-01252

can the job be performed by alternating sitting and standing?YesNoDoesthejobrequireusingthefeettooperatefootcontrols?YesNoIfyes,onwhattypeofequipment?Howimportantisgoodvisioninthejob?

Whatarethemajortasksrequiringuseofoneorbothhands? OneHand BothHands

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

c. information about the job as it relates to the disabilityCanthejobbemodifiedtoaccommodatethedisabilityeithertemporarilyorpermanently?YesNoIfyes,explain

Isitpossibletooffertheemployeeassistanceindoingthejob(throughuseoftechnologyorpersonalassistanceforexample)?YesNoIfyes,explain

d. attachments and signature (Attachacopyoftheemployee’sjobdescription)

Nameofpersoncompletingthisform

X _______________________________________________________ _____________________________________ __________________Signature Title Date

Telephone Fax

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 6 of 14 GLC-01252

GROUP lOnG-teRm disability claim aPPlicatiOn

emPlOyee -formcompletioninformation

aPPlicatiOn FOR GROUP ltd - instructions

A. complete and sign the authorization on the reverse side of this page.Thiswillallowourinsurancecarrierortheirrepresentativetosecureadditionalinformation(ifnecessary)tomakeadecisiononyourrequestforbenefitpayments(donotdetach).

B. complete employee claim statement in full.

attach d AcopyofSocialSecurityandotherincomeentitlementawards(orforwardwhenreceived)

C. Give this authorization and attached claim application to the physician treating you(ifmorethanone,obtainotherformsforcompletionfromemployer).Instructyourattendingphysiciantosendhisstatementalongwithyourstotheinsurancecarrier.

D. WhenthoseformsarereceivedbytheInsuranceCompany,theywilladviseyouofyoureligibilityforbenefitsorofanyadditionalinformationthatmaybeneeded.

DoNotDetach

The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 7 of 14 GLC-01252

Disability

aUtHORiZatiOn FOR Release OF inFORmatiOn

1. i (the undersigned) authorizeanyphysician,medicalprofessional,pharmacistorotherproviderofhealthcareservices,hospital,clinic,othermedicalormedicallyrelatedfacility;insuranceorreinsurancecompany;governmentagency;departmentoflabor;acquaintance;grouppolicyholder;employer;orpolicyorbenefitplanadministratortoreleaseinformationfromtherecordsof:

Claimant/PatientName:______________________________________________________________________________________(Last) (First) (Middle)

DateofBirth:______________________________________ SocialSecurityNumber:_________________________________

2. Informationtobereleased:

d dataorrecordsregardingmymedicalhistory, treatment,prescriptions,consultations [includingmedicalandpsychologicalreports,records,charts,notes(excludingpsychotherapynotes),x-rays,filmsorcorrespondence,andanymedicalconditionImaynowhaveorhavehad];

d anyinformationregardinginsurancecoverage;and

d anyinformation,dataorrecordsregardingmyactivities(includingrecordsrelatingtomySocialSecurity,Workers’Compensation,RetirementIncome,financial,earningsandemploymenthistory).

3. Informationtobereleasedto: TheLincolnNationalLifeInsuranceCompanyPOBox2609Omaha,NE68103-2609

4. IunderstandtheinformationobtainedbyuseofthisAuthorizationwillbeusedbyTheLincolnNationalLifeInsuranceCompany(“Company”)toevaluatemyclaimfordisabilitybenefits.TheCompanywillonlyreleasesuchinformation:

d toitsreinsurer,orotherpersonsororganizationsperformingbusinessorlegalservicesinconnectionwithmyclaim(s);or

d toavendor,approvedbythecompany,whichspecializesintheapplicationforSocialSecurityDisabilityBenefits

d tovendors/consultantsprovidingtheclaimantwithwellness,disabilityorleaverelatedservicesaspartofanemployersponsored benefitplan

d totheemployerforself-insureddisabilityplans;or

d asotherwisemayberequiredbylaworasImayfurtherauthorize.

IfurtherunderstandthatrefusaltosignthisAuthorizationmayresultinthedenialofbenefits.

5. Iunderstandtheinformationusedordisclosedmaybesubjecttore-disclosurebytherecipientandmaynolongerbeprotectedbythefederalHIPAAPrivacyRule.ForColoradoclaims,thedisclosedinformationmaynotberedisclosedorreusedbytherecipientunderColoradolaw.

6. IunderstandthatImayrevokethisAuthorizationinwritingatanytime,excepttotheextent:

1. theCompanyhastakenactioninrelianceonthisAuthorization;or

2. theCompanyisusingthisAuthorizationinconnectionwithacontestableclaim.Ifwrittenrevocationisnotreceived,thisAuthorizationwillbeconsideredvalidforaperiodoftimenottoexceed24monthsfromthedateofmysignaturebelow.ToinitiaterevocationofthisAuthorization,directallcorrespondencetotheCompanyattheaboveaddress.

7. AphotocopyofthisAuthorizationistobeconsideredasvalidastheoriginal.

8. IunderstandIamentitledtoreceiveacopyofthisAuthorization.

siGnatURe:___________________________________________________________ date:___________________________Claimant/legalrepresentative(Nearestrelative,legalguardian,orappointedrepresentativetosignonlyifclaimant/patientisaminor,legallyincompetent,ordeceased.)Powerofattorneyorguardianshipmustbeattached.

PRINTNAME:___________________________________________________________

RelationshiptoClaimant/Patientofpersonal/legalrepresentativesigningforClaimant/Patient: ________________________________

ADDRESS:_________________________________________________________ PHONENO: ___________________________(Street)

_________________________________________________________(City) (State) (ZipCode)

The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com

Page 8 of 14 GLC-01252

FRaUd nOtices. For your protection, certain states require that the following notices appear on this form.

alaska.Apersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveaninsurancecompanyfilesaclaimcontainingfalse,incompleteormisleadinginformationmaybeprosecutedunderstatelaw.

arizona.ForyourprotectionArizonalawrequiresthefollowingstatementtoappearonthisform.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossissubjecttocriminalandcivilpenalties.

arkansas, louisiana, Rhode island and West Virginia.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.

california.ForyourprotectionCalifornialawrequiresthefollowingtoappearonthisform:Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.

colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to aninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialof insuranceandcivildamages.Any insurancecompanyoragentofan insurancecompanywho knowingly provides false, incomplete, ormisleading facts or information to a policyholder orclaimantfor thepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshallbereported to theColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.

delaware.Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,filesastatementofclaimcontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

district of columbia.Itisacrimetoprovidefalseormisleadinginformationtoaninsurerforthepurposeofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines.Inaddition,aninsurermaydenyinsurancebenefitsiffalseinformationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.

Florida.Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimorapplicationcontaininganyfalse,incomplete,ormisleadinginformationisguiltyofafelonyofthethirddegree.

idaho.Anypersonwhoknowingly,andwithintenttodefraudordeceiveanyinsurancecompany,filesastatementorclaimcontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

indiana.Apersonwhoknowinglyandwithintenttodefraudaninsurerfilesastatementofclaimcontaininganyfalse,incomplete,ormisleadinginformationcommitsafelony.

Kentucky.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesa statement of claim containing anymaterially false information or conceals, for the purpose ofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrime.

maine.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,finesoradenialofinsurancebenefits.

maryland.Anypersonwhoknowinglyandwillfullypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglyandwillfullypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.

minnesota.Apersonwhofilesaclaimwithintenttodefraudorhelpscommitafraudagainstaninsurerisguiltyofacrime.

new Hampshire.Anypersonwho,withapurposetoinjure,defraudordeceiveanyinsurancecompany,filesastatementofclaimcontaininganyfalse, incompleteormisleadinginformationissubject toprosecutionandpunishmentforinsurancefraud,asprovidedinRSA638:20.

Page 9 of 14 GLC-01252

new Jersey.Anypersonwhoknowinglyfilesastatementofclaimcontaininganyfalseormisleadinginformationissubjecttocriminalandcivilpenalties.

new mexico.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttocivilfinesandcriminalpenalties.

new york.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor insuranceorstatementofclaimcontaininganymateriallyfalse informationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjecttoacivilpenaltynottoexceedfivethousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.

Ohio.Anypersonwho,withintenttodefraudorknowingthatheisfacilitatingafraudagainstaninsurer,submitsanapplicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.

Oklahoma.Anypersonwhoknowingly,andwith intent to injure,defraudordeceiveany insurer,makesanyclaimfortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

Oregon.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherperson:(1)filesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation;or,(2)concealsforthepurposeofmisleading,informationconcerninganymaterialfact,mayhavecommittedafraudulentinsuranceact.

Pennsylvania.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.

Puerto Rico.Anypersonwhoknowinglyandwiththeintentionofdefraudingpresentsfalseinformationinaninsuranceapplication,orpresents,helps,orcausesthepresentationofafraudulentclaimforthepaymentofalossoranyotherbenefit,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,uponconviction,shallbesanctionedforeachviolationwiththepenaltyofafineofnotlessthanfivethousanddollars($5,000)andnotmorethantenthousanddollars($10,000),orafixedtermofimprisonmentforthree(3)years,orbothpenalties.Shouldaggravatingcircumstancesarepresent,thepenaltythusestablishedmaybeincreasedtoamaximumoffive(5)years,ifextenuatingcircumstancesarepresent,itmaybereducedtoaminimumoftwo(2)years.

tennessee and Washington.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.

texas.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.

FOR all OtHeR states eXclUdinG cOnnecticUt, Kansas, and ViRGinia.Apersonmaybecommittinginsurancefraud,ifheorshesubmitsanapplicationorclaimcontainingafalseordeceptivestatementwithintenttodefraud(orknowingthatheorsheishelpingtodefraud)aninsurancecompany.

Page 10 of 14 GLC-01252

long-term disability claim employee’s statement

to be completed by the employee

a. information about you

LastName First MiddleInitial

Address City State/Province Zip

Telephone SocialSecurityNumber

DateofBirth(Month,Day,Year) Height Weight RtHandedLt.Handed

MaleFemale

SingleMarried

WidowedDivorced

YourEmployer(includedivisionifapplicable)

Occupation

b. information about your family(requiredtodetermineyoureligibilityforSocialSecuritybenefits)

Spouse’sName(Last,First)

Spouse’sSocialSecurityNumber DateofBirth(Month,Day,Year) Isyourspouseemployed?YesNo

Childrenunderage25:Name(Last,First) DateofBirth(Month,Day,Year)

c. information about the condition causing your disability1. Forpregnancyorillness,answerthefollowingquestions:

Whatwereyourfirstsymptoms?

Whendidyoufirstnoticethem? Dateyouwerefirsttreatedbyaphysician(Month,Day,Year)

2. Foraninjury,answerthefollowingquestions:

Whereandhowdidtheinjuryoccur?

Datetheinjuryoccurred(Month,Day,Year) Dateyouwerefirsttreatedbyaphysician(Month,Day,Year)

3. Forillnessorinjury,answerthefollowingquestions:

Whyareyouunabletowork?

Beforeyoustoppedworking,didyourconditionrequireyoutochangeyourjoborthewayyoudidyourjob?YesNoIfyes,explain

Isyourconditionrelatedtoyouroccupation?YesNoIfyes,explain

Haveyoufiled,ordoyouintendtofileaWorkers’Compensationclaim?YesNo

Doyourequireanotherperson’sactive,hands-onhelptosafelyperformactivitiesofdailyliving?YesNoIfyes,pleaseexplainwhatkindofhelpyoureceiveandwhoprovidesit:

d. information about the disability

Lastdayyouworkedbeforethedisability(Month,Day,Year)

Didyouworkafullday?YesNoIfno,explain

Dateyouwerefirstunabletowork?(Month,Day,Year)

Haveyoureturnedtowork?YesParttime(date)_____________Fulltime(date)_____________No

Ifyouhavenotreturnedtowork,doyouexpectto?YesParttime(date)_____________Fulltime(date)_____________No

Areyoucurrentlyself-employedorworkingforanotheremployer?YesNoIfso,givedetails.

(Continuedonnextpage)

Page 11 of 14 GLC-01252

e. information about physicians and hospitals

Firstmedicalattentionforthecurrentdisabilitywasgivenby(completebelow):Doctor’sName Telephone:

Fax:Specialty

Address(Street,City,State,Zip) DatesSeenTo

Listallotherphysiciansandhospitalsyouhaveseenforthiscondition:Doctor’sName Telephone:

Fax:Specialty

Address(Street,City,State,Zip) DatesSeenTo

Doctor’sName Telephone:Fax:

Specialty

Address(Street,City,State,Zip) DatesSeenTo

Doctor’sName Telephone:Fax:

Specialty

Address(Street,City,State,Zip) DatesSeenTo

Hospital Telephone:Fax:

Specialty

Address(Street,City,State,Zip) DatesofConfinementTo

Haveyoueverhadthesameorasimilarconditioninthepast?YesNoIfyes,completethefollowingconcerningyourpasttreatment:Doctor’sName Telephone:

Fax:Specialty

Address(Street,City,State,Zip) DatesSeenTo

Hospital Telephone:Fax:

Specialty

Address(Street,City,State,Zip) DatesofConfinementTo

F. information about other disability income(Checktheotherincomebenefitsyouarereceivingorareeligibletoreceiveasaresultofyourdisabilityandcompletetheinformationrequested.)

SourceofIncome Amount (wk.,mon.) Dateclaimwasfiled Datepaymentsbegan Datepaymentsended

SocialSecurityRetirement $________________ /

SocialSecurityDisability/Yourself $________________ /

SocialSecurityDisability/Dependents $________________ /

CanadianPensionPlan $________________ /

Workers’Compensation $________________ /

StateDisability $________________ /

Pension/Retirement $________________ /

Pension/Disability $________________ /

ShortTermDisability $________________ /

Unemployment $________________ /

No-FaultInsurance $________________ /

RailroadRetirement $________________ /Other(includeindividualorgroupbenefits): $________________ /

G. information about income tax withholdingIfyourrequestforbenefitsisapproved,shouldTheLincolnNationalLifeInsuranceCompanywithholdincometaxesfromyourbenefitchecks?YesNoIfyes,howmuchshouldbewithheldfromeachcheck.Federaltaxes(minimumis$88.00permonth)$_____________.00H. signature(Requiredforallclaims)

UnderwhatotherTheLincolnNationalLifeInsurancepoliciesareyoucurrentlycovered?TheaboveStatementsaretrueandcompletetothebestofmyknowledgeandbelief.IhavereadandunderstandtheattachedFraudWarningstatements.

X ______________________________________________________________________________ __________________________________ SignatureofEmployee Date

Page 12 of 14 GLC-01252

long-term disability claim Physician’s statementThisformshouldbecompletedbythephysicianwhowastreatingtheclaimantwhenheorshelastworked.

ToBeCompletedByTheAttendingPhysician

a. General information

Thisclaimisfor(Patient’sName)

Patient’sSocialSecurityNumber Height Weight BloodPressure DateofBirth(Month,Day,Year)

PrimaryDiagnosisincludingICD9orDSMcode

b. complete this section for normal pregnancy, then go to section e.

Whatwasthedateofthelastmenstrualperiod? Whatistheexpecteddateofdelivery?

Whatistheexpectedlengthofpostpartumrecovery? Whatwasthefirstdateoftreatment? Whatwasthelastdateoftreatment?

c. complete this section for all conditions except normal pregnancy.

Symptoms

ObjectiveFindings

Aretheresecondaryconditionscontributingtothedisability?YesNoIfyes,whatarethey?(PleaseincludeICD9orDSMcode.)

Ifthisisacardiaccondition,whatisthefunctionalcapacity?(AmericanHeartAssociation)

Class1-NolimitationClass2-Slightlimitation

Class3-MarkedlimitationClass4-Completelimitation

Whendidsymptomsfirstappear? Dateofthepatient’sfirstvisit(Month,Day,Year)

Dateyoubelievethepatientwasfirstunabletowork(Month,Day,Year)

Dateofthepatient’slastvisit(Month,Day,Year)

Howoftendoyouseethepatient?

Isthepatient’sconditionworkrelated?YesNoIfyes,explain:

Hasthepatientundergonesurgery?YesNoIfyes,givedate,procedureandresult.

Ifno,doyouexpectsurgerytobeperformedinthefuture?YesNoIfyes,givedateandtypeofsurgery.

Whatmedicationisthepatientcurrentlytaking?

Pleaseindicateothertypesandfrequenciesoftreatment.

Hasthepatientbeenreferredtoamedicalrehabilitationortherapyprogram?YesNoIfyes,givedetails.

Haveyoureferredthepatientforothertypesofconsultations?YesNoIfyes,givedetails.

Hasthepatientbeenhospitalconfined?YesNoIfyes,completethefollowing:

NameofHospital

Address DatesofConfinementthrough

Page 13 of 14 GLC-01252

d. information about the patient’s inability to workBrieflydescriberestrictionsandlimitations.

Restrictions(WhatthepatientSHOULDNOTdo)

Limitations(WhatthepatientCANNOTdo)

Whatisyourprognosisforrecovery?

Haspatientachievedmaximummedicalimprovement?YesNoIfno,completethefollowing:

Howsoondoyouexpectfundamentalchangesinthepatient’smedicalcondition?1-2months 5-6months3-4months morethan6monthsGivedetailsconcerningexpectedimprovementordeterioration:

Inaneighthourworkday,claimantcan:(Circlefullhourlycapacityforeachactivity)Sit 1 2 3 4 5 6 7 8Stand 1 2 3 4 5 6 7 8Walk 1 2 3 4 5 6 7 8

Arethererestrictionsin: Yes No Comments

Lifting/Carrying ___________________________________________________________________________

Useofhandsinrepetitiveactions ___________________________________________________________________________

Useoffeetinrepetitivemovements ___________________________________________________________________________

Bending ___________________________________________________________________________

Squatting ___________________________________________________________________________

Crawling ___________________________________________________________________________

Climbing ___________________________________________________________________________

Reachingaboveshoulderlevel ___________________________________________________________________________

Other(pleasespecify) ___________________________________________________________________________

Whendoyouexpectclaimanttoreturntopriorleveloffunctioning?

Wouldyourecommendvocationalrehabilitationforthispatient?YesNo

Hasyourpatienthadlossofcognitivefunctioning?“Cognitiveimpairment”meansapermanentdeteriorationorlossofcognitiveorintellectualcapacityandrequiresanotherperson’shands-onhelporverbalcuestopreventharmtoselforothersduetoimpairmentYesNoIfyes,pleaseexplainandprovidesupportingmedicaldocumentationandtesting:

Basedonyourobservationsofthispatient,medicalhistoryandcondition,hasyourpatientlosttheabilitytosafelyandcompletelyperformActivitiesofDailyLiving(ADLs)withoutanotherperson’sactivehands-onhelpwithallormostoftheactivity:

ADL Dateonwhichassistancewasfirstrequiredandreceived

Bathing_______________(washingselfintub,showerorbyspongebath,withorw/oequipment)

Dressing______________(puttingon,takingoffgarmets,bracesoranyartificiallimbsnormallyworn)

Toileting______________(gettingto,from,onandofftoilet;andperformingrelatedpersonalhygiene)

Transferring___________(movingin&outofbed,chairoranywheelchair,withorw/oequipment)

Continence____________(voluntarilymaintainingcontrolofbladderandbowelfunction)

Eating________________(gettingnourishmentintoone’sbodybyanymeans(table/trayorspecialequipment)

IftheclaimanthaslosttheabilitytoperformADLslistedabove,pleaseprovideanysupportingmedicaldocumentationandtesting.

IfthepatienthaslosttheabilitytoperformanyADLslistedabove,doyouexpectthelimitationstobepermanent?YesNoIf“no”,pleaseexplainwhenimprovementmaybeexpected:

Page 14 of 14 GLC-01252

e. Required attachments and signature

after you have fully completed this form, attach copies of the following materials:– Office notes for the period of treatment for the last two years– test results showing objective findings– Hospital discharge summaries– consulting physician reports

YourName Degree

Specialty Telephone:Fax:

Address

X ______________________________________________________________________________ __________________________________SignatureofAttendingPhysician(nostamp) Date