Customer Service Request

Service Request

		*Required Fields
	Policy Number:*
	Name:*
	Street Address:*
	Address (cont.) :
	City:*	State:* Zip:*
	Country:*
		Please check if this is a new address.
	Phone:	(i.e.: 123-456-7890)
	E-mail Address:*

		Select any of the options that apply:
		Beneficiary Change
		Ownership Change
		Bank Change
		If Bank Change is checked, do you want us to continue with the current draft from old bank? Yes No
		Duplicate Policy
		Reinstatement
		Loan Request
		Cancellation of Policy
		If you are canceling your policy, a reason must be given for cancellation.
		Request for Additional Insurance If you are requesting additional insurance an agent will be notified so they may contact you.
		Best time of day to reach you:
		Please allow five business days for your request to be processed or mailed.

©2002 Lincoln Heritage Life Insurance Company. All Rights Reserved. Privacy Statement.
4343 East Camelback Road, Phoenix, AZ 85018. Telephone: 1-800-433-8181