Fillable 4404 Mutual Of Omaha- Evidence Of Insurability (City of Bisbee)

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4404 Mutual Of Omaha- Evidence Of Insurability (City of Bisbee)

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A Guide for Successfully Completing the
Group Insurance Evidence of Insurability Form
United of Omaha Life Insurance Company (United of Omaha) appreciates the opportunity to provide you with
valuable insurance protection for
yourself
and/or your loved ones. So that we can effectively determine if you
qualify for group insurance (whether
you
are seeking new coverage or additional coverage), we rely on the
information you provide on this
form.
This guide provides information and instruction to help you successfully complete and submit the form.
Please
consult your employer/benefits administrator if you need assistance with information for the
form.
Please Note: The evidence of insurability form should only be completed if these coverages are provided by
your employer through United of Omaha.
SUBMISSION OPTIONS
! An electronic version can be completed online at
www.mutualofomaha.com/eoi
! Complete the attached form and mail it to
United
of
Omaha Life Insurance Company
.
IMPORTANT TIPS FOR PAPER COPY SUBMISSION
! All sections of the form are to be completed by the
employee. Make sure you provide all required information
and answer all questions completely and accurately. If
information is missing or is illegible (unreadable), the
processing of your form will be delayed.
! Refer to the guidelines for each section below, which
provide valuable information to help you successfully
complete the form.
! Make a copy of the completed form for your records
before submitting to United of Omaha.
GUIDELINES FOR SECTION 1: POLICYHOLDER/EMPLOYER
INFORMATION
The Group ID Number for your employer will have eight
characters, beginning with “G000” followed by four
additional letters or numbers specific to your employer.
GUIDELINES FOR SECTION 2: EMPLOYEE/MEMBER
CONTACT & EMPLOYMENT INFORMATION
Employment information is for your current employer
(identified in Section 1) and your current job.
GUIDELINES FOR SECTION 3: APPLICANT (PROPOSED
INSURED) INFORMATION
In this section, you only provide information for those
applying
for
coverage, whether yourself (the
employee),
your eligible dependents, or a combination thereof.
(For
example, if you are only applying for insurance
for yourself and your spouse, you would not provide
information
for
any
children.)
Be sure to provide weight in pounds, and height in feet
and inches, for all
applicants
.
GUIDELINES FOR SECTION 4: REQUESTED INSURANCE
Indicate the type(s) of insurance you are applying for,
whether life, short-term disability or long-term disability.
The evidence of insurability form should only be
completed if the coverages are provided by your
employer through United of Omaha.
GUIDELINES FOR SECTION 5: REQUESTED LIFE
INSURANCE BENEFIT AMOUNT
Helpful Hints for (1) Current Amount of
Insurance
! If you recently enrolled for life insurance and are applying
for coverage in excess of the Guarantee Issue amount,
the Guarantee Issue amount is the current amount you
should provide.
! If you have had life insurance for some time, and are
applying to increase the amount of coverage you have,
provide the current amount of coverage you have. Please
contact your employer/benefits administrator to confirm
current amount(s) if you are uncertain.
! If you (or a dependent) do not currently have coverage,
enter 0 (zero).
Helpful Hints for (2) Additional Requested
Amount
! This amount is the difference between any current amount
you have and the total amount of insurance you would like
to have.
! The total amount of insurance available is subject to plan
maximums. Consult your employer for additional plan
specific information, if needed.
For (3) Total Amount of Insurance Requested, indicate
the total amount of life insurance you would like to
have.
ALLPROD-EOI-13
GUIDELINES FOR SECTION 6: HEALTH INFORMATION
FOR LIFE AND/OR DISABILITY (STD OR LTD)
INSURANCE
!
The health information provided in this section is
used to underwrite your application for
insurance.
! Be sure to answer all questions as honestly and
accurately as possible, and provide additional
information where indicated.
! For Degree of Recovery, indicate the percent of
function you have recovered. (100% indicates full
recovery. Any lesser percentage would be a judgment
of partial recovery.)
! If you are only applying for coverage for yourself,
then answer these questions for yourself only. If you
are applying
for
coverage for any dependents, then
answer these questions for anyone included on
the
form.
GUIDELINES FOR SECTION 8: AUTHORIZATION TO
DISCLOSE PERSONAL INFORMATION & APPLICATION
FOR INSURANCE
Please read this section in its entirety. By signing, you
are applying for insurance coverage with United of
Omaha, and are agreeing to allow disclosure of
personal
information to the necessary parties for purposes of
underwriting your
application.
For any applicant, if the name associated with any
medical records differs from the name provided on the
form, provide any alternate names. This might occur
in the event of a name change due to marriage or
adoption, for
example.
To be complete, the form must be signed by you, and
must also be signed by your spouse if your spouse is
applying
for
coverage.
United of Omaha Life Insurance Company
Home Office: Mutual of Omaha Plaza, Omaha, Nebraska 68175 Phone: (800) 948-9478
Group Insurance Evidence of Insurability Form
Please print clearly in blue or black ink. All required information should be completed to avoid any delays in the
processing of this application. No amount of insurance for which evidence of insurability is required will be effective until
approved by the underwriting company. When complete, to help ensure efficient processing and protect your information,
mail the completed application to:
Attn: Group Underwriting Individual Selection
Mutual of Omaha
Mutual of Omaha Plaza
Omaha, NE 68175
Section 1: Policyholder/Employer Information (Required fields are marked with an asterisk (*).)
Policyholder/Employer Name*
City*
State*
__ __
Section 2: Employee/Member Contact & Employment Information (Required fields are marked with an asterisk (*).)
Last Name*
First Name*
MI
Street Address*
Email Address
City*
State*
ZIP Code*
Telephone*
__ __
__ __ __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
Full-Time Employment Date (MM/DD/YYYY)*
Annual Salary*
Job Title/Description*
Avg. Hours Worked/Week
Section 3: Applicant (Proposed Insured) Information (Required fields are marked with an asterisk (*).)
Part A – Complete if the Employee/Member is Applying for Insurance
Birth Date (MM/DD/YYYY)*
State of Birth*
Gender*
Weight*
Height*
__ __
F M
Lbs.
Ft. In.
Part B – Complete if Applying for Spouse Insurance (for Life Insurance only)
Last Name*
First Name*
MI
Birth Date (MM/DD/YYYY)*
State of Birth*
Gender*
Weight*
Height*
__ __
F M
Lbs.
Ft. In.
Note: For all states except AR, KS, and KY, use of the term “spouse” on this application refers to the person to whom you are legally married; or if the
policyholder/employer allows or as required by law, your domestic or civil union partner or equivalent, as allowed by federal or state law, or law of the county, city or
local government where you live.
Part C – Complete if Applying for Child(ren) Insurance (for Life Insurance only)
Last Name*
First Name*
Gender*
Birth Date (MM/DD/YYYY)*
Weight*
Height*
F M
Lbs.
Ft. In.
F M
Lbs.
Ft. In.
F M
Lbs.
Ft. In.
F M
Lbs.
Ft. In.
Note: If you apply for one child, you must apply for all eligible children. Attach a list of additional children with the above information if necessary.
Section 4: Requested Insurance
Select each insurance product for which you are applying:
Life Short-Term Disability (STD) Long-Term Disability (LTD)
Section 5: Requested Life Insurance Benefit Amount (Required fields are marked with an asterisk (*).)
Employee/Member
(IF APPLICABLE)
Spouse
(IF APPLICABLE)
Child(ren)
(IF APPLICABLE)
(1) Current Amount of Insurance (IFANY)
(2) Additional Requested Amount
(3) Total Amount of Insurance Requested* (1+2)
ALLPROD-EOI-13
PAGE 1 OF 4; FORM CONTINUES ON PAGE 2
EMPLOYEE/MEMBER NAME* _____________________________________________________________________
PAGE 2 OF 4
Section 6: Health Information for Life and/or Disability (STD or LTD) Insurance (A response is required for each question for each applicant.)
Part A
1 – During the past 5 years, has any person proposed for insurance ever been diagnosed by or received medical care from a medical professional
for; or for residents of all states except GA, had any disease or disorder associated with; any of the following: (Check all that apply)
Condition
Member
Spouse
Child(ren)
Condition
Member
Spouse
Child(ren)
Urinary tract or kidney?
Lung or respiratory disorder?
Liver or hepatitis?
Chronic fatigue syndrome?
Anemia or blood (except HIV)?
Arthritis or joints (incl. replacements)?
Skin or connective tissue?
Epilepsy or any nervous, mental or
emotional disorder?
Chronic Epstein-Barr?
Cancer or tumor?
Breasts or reproductive organs (incl.
implants, infertility, irregular cycles,
pregnancy complications)?
Alcohol or drug abuse?
Spine, neck or back?
Fibromyalgia or myalgia?
Neurological condition (incl. Multiple
Sclerosis, Parkinson’s, seizures,
Alzheimer’s)?
High blood pressure, arteries or veins?
Stroke or cerebral vascular condition?
Diabetes or glandular condition?
Any disease of the immune system
(except HIV)?
Stomach, upper or lower digestive tract?
Coronary arteries of the heart?
Member
Spouse
Child(ren)
2 – During the past 5 years, has any person proposed for insurance ever been diagnosed or treated (including
medication or recommendation for treatment) by a member of the medical profession for: Acquired Immune
Deficiency Syndrome (AIDS); for residents of all states except CO or IN, AIDS Related Complex (ARC); or for
residents of all states except CA, IN, ME, NY, VA or VT, Human Immunodeficiency Virus (HIV) infection
(symptomatic or asymptomatic)? Notice for Residents of CA: California law prohibits an HIV test from being
required or used by health insurance companies as a condition of obtaining health insurance coverage. Notice
for Residents of FL and VT: The applicant(s) do not have to disclose information relating to AIDS, ARC or
HIV unless the diagnosis of those conditions has been made by a licensed physician. Notice for Residents of
ME: Answer this question “NO” if the person proposed for insurance has tested positive for HIV but has not
developed symptoms of the disease AIDS or ARC. Notice for Residents of MN: The applicant(s) do not have
to disclose an HIV (AIDS Virus) test or test to determine a blood-borne pathogen which was administered: (1)
to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who
received the services of emergency medical service personnel at a hospital or medical care facility; or (3) to
emergency medical service personnel who were tested as a result of performing emergency medical services.
Yes
No
Yes
No
Yes
No
3 – During the past 5 years, other than for questions 1 and 2 above, has any person proposed for insurance:
(For residents of NJ: Are any of the following applicable to any person proposed for insurance?)
Yes
No
Yes
No
Yes
No
! Been diagnosed or treated by a medical professional?
! Had surgery or been hospitalized?
! Had a medical or diagnostic examination or evaluation?
! Had or been advised to seek treatment for any illness,
injury or disorder (except HIV)?
! Received medical care?
Notice for Residents of ME: Answer this question “NO” if the person proposed for insurance has tested
positive for HIV but has not developed symptoms of the disease AIDS or ARC.
4 – Has any person proposed for insurance been absent from work for more than 5 consecutive working days
because of illness or injury during the past five years?
Yes
No
Yes
No
Yes
No
5 – Within the past 6 months, has any person proposed for insurance been prescribed medication by a medical
professional or taken any medication requiring a prescription?
Yes
No
Yes
No
Yes
No
6 – During the past 5 years, has any person proposed for insurance regularly used unlawful drugs (including
cocaine, hallucinogens or narcotics), or regularly used prescription drugs other than as prescribed (including
sedatives, tranquilizers or narcotics), in any form?
Yes
No
Yes
No
Yes
No
7 – If female, are you pregnant?
If Yes, please provide anticipated delivery date (MM/DD/YYYY): ____/____/________
Yes
No
NA
NA
Part B – For any questions in Part A answered with “Yes”, except for questions about HIV/AIDS/ARC, the following must be completed, as applicable.
Requested dates should be in MM/DD/YYY format. Attach a separate signed and dated sheet containing additional information if necessary.
Ques.
#
Name of Applicant
Date of
Occurrence
Date of
Recovery
Current Status/
Degree of Recovery
Diagnosis/Condition/Treatment/
Medication/Exam Results
Attending Physician’s
Name, Address & Phone
ALLPROD-EOI-13
PAGE 2 OF 4; FORM CONTINUES ON PAGE 3
EMPLOYEE/MEMBER NAME* _____________________________________________________________________
PAGE 3 OF 4
Part C – If you responded YES to question 5 above for any proposed insured, you must complete the following, as applicable. Attach a separate signed and dated
sheet containing additional information if necessary.
Medication Name
(FROM PRESCRIPTION LABEL)
Dosage/Frequency
Dates Taken
(MM/DD/YYYY - MM/DD/YYYY)
Section 7: Required Fraud Warnings – Please Read (State specific warnings apply to the residents of each specific state.)
Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties. (Note: This fraud warning does not apply to residents of AL, AR, CA, CO, DC, FL, KS, KY, LA, ME, MD, NJ, NM, NY, OH,
OR, PR, RI, TN, VT, VA and WA. If you are a resident of one of these states, please refer to the attached list for the specific fraud
warning for your place of residence.)
Section 8: Authorization to Disclose Personal Information & Application for Insurance
Part A – Definitions of Terms Used in Section 10
! Medical Persons and Entities means all physicians, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit
managers, other medical care facilities, health maintenance organizations and all other providers of health care services.
! MIB Group, Inc. (MIB) means a non-profit membership organization of life insurance companies that operates an information
exchange on behalf of its members.
! Personal Information means all health information such as medical history, prescription drug records, mental and physical condition,
and drug and alcohol use, and other information such as finances, occupation, general reputation, insurance claims, motor vehicle
reports and criminal activity. Personal information does not include psychotherapy notes.
! Specified Companies means the group of companies which presently includes Mutual of Omaha Insurance Company, United of
Omaha Life Insurance Company, Companion Life Insurance Company, additional companies which may become a part of this group
of companies (and their successors), and other persons and/or entities which act on behalf of these companies to provide services to
them.
Part B – Authorization to Disclose Information
I authorize the Medical Persons and Entities, the Specified Companies, employers, consumer reporting agencies and other insurance
companies to disclose Personal Information about me and my child(ren) to United of Omaha Life Insurance Company. Personal
Information received (a) will be used in connection with the underwriting of insurance; and (b) will assist in verifying the accuracy of the
information provided in this application for insurance; and (c) will assist in resolving any issues that may arise in connection with a
claim. For residents of CA: This authorization excludes the release of any information relating to any previous tests for HIV Antibodies,
T-Cell Counts, AIDS or ARC by any person or entity that may possess such information. For residents of ME: This authorization
excludes disclosure of the result of a test for HIV if the applicant has not developed symptoms of the disease AIDS or ARC. Such test
results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the
applicant has AIDS or ARC. For residents of OK: Such release may include information, which may indicate the presence of a
communicable or venereal disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea,
Human Immunodeficiency Virus (HIV) infection, and Acquired Immune Deficiency Syndrome (AIDS). For residents of VT: This
authorization prohibits the release of any information relating to any new tests for HIV Antibodies, T-Cell Counts, AIDS or ARC by
United of Omaha Life Insurance Company to any outside, non-affiliated company nor to any entity not under specific contract with the
company to perform underwriting services.
If the person or entity to whom Personal Information is disclosed is not a health care provider or health plan subject to federal privacy
regulations, the Personal Information may then be subject to further disclosure by that person or entity without the protections of federal
privacy regulations. Unless revoked earlier, this authorization will remain in effect for 12 months from the date the application is signed.
If I am a resident of AZ, disclosure of HIV-related information is only authorized for 180 days from the date the application is signed. I
understand I may revoke this authorization at any time by providing written notice to the address provided at the beginning of this form.
I understand the revocation may not take effect before the date it is received by United of Omaha Life Insurance Company.
Name(s) used for medical records for any proposed insured (if different than the name(s) provided on this form):
__________________________________________________________________________________________________________
Part C – Authorization to Receive and Disclose Information to the MIB
I authorize the MIB to disclose Personal Information for me (the undersigned) and my child(ren) to the Specified Companies. You are
not authorized to disclose Personal Information to a consumer reporting agency. Personal Information received (a) will be used in
connection with the underwriting of insurance; and (b) will assist in verifying the accuracy of the information provided in this application
for insurance; and (c) will assist in resolving any issues that may arise in connection with a claim.
I also authorize the Specified Companies to disclose Personal Information for me and my child(ren) to the MIB. I understand that the
Personal Information received by the MIB may be disclosed, upon request, to another member company with whom any person
proposed for insurance applies for life or health insurance or to whom any proposed insured may submit a claim for benefits. Unless
revoked earlier, this authorization will remain in effect for 12 months from the date the application is signed. I may revoke this
authorization at any time by providing written notice to the address provided at the beginning of this form. I understand the revocation
may not take effect before the date it is received by United of Omaha Life Insurance Company.
ALLPROD-EOI-13
PAGE 3 OF 4; FORM CONTINUES ON PAGE 4
EMPLOYEE/MEMBER NAME* _____________________________________________________________________
PAGE 4 OF 4
Section 8: Authorization to Disclose Personal Information & Application for Insurance (Continued)
Part D – Application for Insurance
I apply for insurance for the proposed insured(s) identified in Section 3 of this application who is/are eligible for insurance. Information in
this form is given to obtain the insurance requested and is true and complete, and no important circumstance or information has been
withheld or omitted, to the best of my knowledge and belief. I know that insurance could be void if these answers are not true and
complete. I understand that all statements in this application for insurance are deemed representations and not warranties.
I understand that insurance for new or additional amounts of insurance in excess of any guarantee issue amount for any proposed
insured does not begin until United of Omaha Life Insurance Company approves such person for such amounts, the proposed
insured(s) is/are eligible for the insurance under the terms of the policy, and the appropriate premium is paid. If applicable, I permit my
employer to deduct the premium contribution from my earnings for approved amounts of insurance for any proposed insured.
I understand that this application is only valid for 90 days from my signature date below. I acknowledge that incomplete information on
this application may delay processing. If the Specified Companies request additional medical information to complete processing of this
application, I understand that any delay in my response may make it necessary for me to submit a new application. I understand that I
may refuse to sign this form, and that if I refuse to sign, the insurance I am applying for will not be issued to any proposed insured.
I will retain a copy of this application with my certificate/summary of coverage. I understand that I, or my authorized representative, may
receive a copy of this form upon request. A copy of this form is as effective as the original.
Notice for Residents of MA: Caution! If your answers on this application or incorrect or untrue, United of Omaha Life Insurance
Company has the right to deny benefits or rescind insurance.
By signing below, I acknowledge that: (a) I understand and agree to the terms of this application; (b) this form has been completed in
accordance with the instructions provided; and (c) for residents of all states except CA, I have read the applicable fraud warning for my
state of residence.
SIGNATURE OF EMPLOYEE/MEMBER (REQUIRED) _______________________________________ DATE __ __/__ __/__ __ __ __
SIGNATURE OF SPOUSE (IFAPPLYING FOR INSURANCE) ________________________________________ DATE __ __/__ __/__ __ __ __
SIGNATURE OF CHILD (IFAPPLYING FOR INSURANCE & AGE 18 OR OLDER*) ______________________________ DATE __ __/__ __/__ __ __ __
*AGE 15 OR OLDER FOR RESIDENTS OF WA
FORM IS NOT COMPLETE UNTIL SIGNED AND DATED – RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
ALLPROD-EOI-13
PAGE 4 OF 4
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Fraud Warnings
United of Omaha Life Insurance Company • Mutual of Omaha Insurance Company
Mutual of Omaha Plaza • Omaha, NE 68175-0001
Phone (800) 948-9478 (toll-free) • www.mutualofomaha.com/customer-service
Please review the specific fraud warning for your place of residence prior to signing the attached form or application.
All Other States: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or statement of claim containing any
materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
Alabama: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty
of a crime and may be subject to restitution fines or confinement in
prison, or any combination thereof.
Arkansas/Maine/Ohio/Tennessee: Any person who, with intent
to defraud or knowing that he/she is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or
deceptive statement is guilty of insurance fraud.
California: For your protection, California law requires the
following to appear on this form: Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines and confinement in
state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance,
and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
District of Columbia: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines.
In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the
applicant.
Florida: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
Kansas: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for
insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to
criminal and civil penalties as determined by a court of law.
Kentucky: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for
insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Maryland: Any person who knowingly or willfully presents a false
or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application
for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
New Jersey: Any person who includes any false or misleading
information on an application for insurance is subject to criminal
and civil penalties.
New Mexico: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty
of a crime and may be subject to civil fines and criminal penalties.
New York: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for
insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation.
North Carolina/Oregon: Any person who knowingly and with
intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any
materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto, may
have committed a fraudulent insurance act, which may be a crime
and may subject such person to criminal and civil penalties.
Puerto Rico: Any person who furnishes information verbally or in
writing, or offers any testimony on improper or illegal actions
which, due to their nature constitute fraudulent acts in the
insurance business, knowing that the facts are false shall incur a
felony and, upon conviction, shall be punished by a fine of not
less than five thousand (5,000) dollars, nor more than ten
thousand (10,000) dollars for each violation or by imprisonment
for a fixed term of three (3) years, or both penalties. Should
aggravating circumstances be present, the fixed penalty thus
established may be increased to a maximum of five (5) years; if
extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
Rhode Island: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information on an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Vermont: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for
insurance or statement of claims containing any materially false
information or conceals for the purpose of misleading, information
concerning any fact material thereto may be committing a
fraudulent insurance act, which may be a crime and may subject
such person to criminal and civil penalties.
Virginia: Any person who, with the intent to defraud or knowing
that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement may have violated state law.
Washington: It is a crime to knowingly provide false, incomplete
or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
MUGC9331
PAGE 1 OF 1
NOTICE OF INFORMATION PRACTICES
In the course of properly underwriting and administering your insurance coverage, Mutual of Omaha and its affiliated
companies (“we”) will rely heavily on information provided by you. We may also collect information from others, such as
medical professionals who have treated you, hospitals, other insurance companies, and consumer reporting agencies.
In certain circumstances, and in compliance with applicable law, we or our reinsurers may also release your personal or
privileged information in our/their files, to third parties without your authorization. You have the right to be told about and
to see a copy of items of personal information about you which appear in our files, including information contained in
investigative consumer reports. You also have the right to seek correction of personal information you believe to be
inaccurate.
In compliance with applicable law, we or our reinsurers may also release information in our/their files, including
information in an application, to other insurance companies to which you apply for life or health insurance or to which a
claim is submitted.
So that there will be no question that the insurance benefits will be payable at the time a claim is made, we urge you to
review your application carefully to be sure the answers are correct and complete.
THE ABOVE IS A GENERAL DESCRIPTION OF OUR INFORMATION PRACTICES. IF YOU WOULD LIKE TO RECEIVE A MORE DETAILED
EXPLANATION OF THESE PRACTICES, PLEASE SEND YOUR REQUEST TO – ATTN: GROUP UNDERWRITING INDIVIDUAL SELECTION;
MUTUAL OF OMAHA; MUTUAL OF OMAHA PLAZA; OMAHA, NE 68175.
MIB, INC. PRE-NOTICE
Information regarding your insurability will be treated as confidential. Mutual of Omaha and its affiliated companies, or its
reinsurers may, however, make a brief report thereon to MIB, Inc., a not-for-profit membership organization of insurance
companies, which operates an information exchange on behalf of its Members. If you apply to another MIB, Inc. Member
company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, Inc., upon
request, will supply such company with the information in its file.
Upon receipt of a request from you MIB, Inc. will arrange disclosure of any information it may have in your file. Please
contact MIB, Inc. at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of information in MIB, Inc.’s file,
you may contact MIB, Inc. and seek a correction in accordance with the procedures set forth in the federal Fair Credit
Reporting Act. The address of MIB, Inc.’s information is: 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734.
Mutual of Omaha and its affiliated companies, or its reinsurers, may also release information in its file to other insurance
companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
Mutual of Omaha and its affiliated companies, or its/their duly authorized representative(s), may request and obtain an
investigative consumer report for the purpose of serving as a factor in the underwriting of your insurance application.
An investigative consumer report means any written, oral or other communication of any information by a consumer
reporting agency bearing on your character, general reputation, personal characteristics or mode of living obtained
through personal interviews with your neighbors, friends, acquaintances, associates, or those who may have knowledge
concerning such items of information.
Upon written request we will provide you with additional disclosures relating to the nature and scope of the investigative
consumer report. Following this Disclosure Statement is a written Summary of Your Rights under Section 609 (c) of the
Fair Credit Reporting Act, as amended.
If you request the additional disclosures from either United of Omaha Life Insurance Company or Mutual of Omaha
Insurance Company, please send your request to the following address – Attn: Group Underwriting Individual Selection;
Mutual of Omaha; Mutual of Omaha Plaza; Omaha, NE 68175.
INVESTIGATIVE CONSUMER REPORTS NOTICE
Mutual of Omaha and its affiliated companies (“we”) may request that an investigative consumer report be prepared,
whereby information about you is obtained through personal interviews with your neighbors, friends, associates,
acquaintances or others who may have knowledge relating to your character, general reputation, personal characteristics,
or mode of living. Upon request, we will inform you whether an investigative consumer report was done, and the nature
and scope of the investigation.
You may request to be interviewed in connection with the preparation of an investigative consumer report. You also have
the right, upon request, to receive a copy of the investigative consumer report from the consumer reporting agency that
prepared it.
We will provide you the name, address and telephone number of the consumer reporting agency so that you may request
a copy of any such report directly from the agency. You may question the accuracy or seek correction of information
contained in such report.
ALLPROD-EOI-13
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4404 Mutual Of Omaha- Evidence Of Insurability (City of Bisbee)

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Completed 18 November 2020

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