Fill - Free fillable Tennessee Application for Life Insurance (Duford Insurance Group) PDF form

United of Omaha Life Insurance Company

A Mutual of Omaha Company

Tennessee – Application for Life Insurance

Living Promise Product – One Base Policy per Application

✍

Checklist for Submitting a Complete Application

Please mail application and appropriate forms to: United of Omaha Life Insurance Company,

Attn: Individual Life Underwriting, 9330 State Hwy 133, Blair, NE 68008

FAX: 1-402-997-1800

☞ Please choose the precise Plan, Rider, and amount of insurance applied for

❏ Level Beneﬁt Product:

• Accelerated Death Benefit Rider

• Accidental Death Benefit Rider (optional)

❏ Graded Beneﬁt Product (if available):

• No Riders Available

Application Submission Guidelines

❏ Attach a cover letter or additional information as needed.

❏ Always submit the Producer Report page.

❏ Leave all applicable forms and Life Buyer's Guide with the Proposed Insured.

❏ All changes should be initialed by the Applicant/Owner.

❏ If a Financial Institution would receive compensation for a sale, the Financial Institution Consumer Disclosure must be

signed by the client.

Important Forms

❏ Replacement Notice – if applicable, the client must sign and retain a copy for their records

❏ Payment Authorization – Complete this form if applicable

❏ Conditional Receipt – Complete ONLY if you accepted a check or electronic transaction authorization at time of application

for the initial premium. DO NOT complete the Conditional Receipt if initial payment won't be collected until issue.

❏ Accelerated Benefit Rider Disclosure – The client must sign the Accelerated Benefit Rider Disclosure Form

❏ Authorization for Release of Information to My Insurance Agent, Agency and/or Authorized Third Party Vendor - Complete

this form if applicable. The client must sign and retain a copy for their records.

LAP1162_TN

08/18/2017

Supplemental Forms and Buyer's Guide:

● Buyer's Guide: For all life products, the shopping guide for insurance is to be given to the consumer at point of sale.

ICC14L643A PLEASE SUBMIT ALL PAGES

PROPOSED INSURED

United of Omaha Life Insurance Company

A Mutual of Omaha Company

Mutual of Omaha Plaza, Omaha, NE 68175

Part One IF THE PROPOSED INSURED ANSWERS “YES” TO ANY QUESTIONS IN PART ONE, THAT PERSON IS NOT

ELIGIBLE FOR ANY COVERAGE UNDER THIS APPLICATION.

Application for Individual Life Insurance

UNDERWRITING

Name (First, Middle Initial, Last) Sex

■ Male ■ Female

Height Weight Social Security No.

Home Address (Street, City, State, Zip) State of Birth Date of Birth Age

Phone No. E-mail Driver’s License No. Driver’s License State

Are you a legal resident of the United States? ■ Yes ■ No

(If “No”, you are not eligible for coverage.)

In the past 12 months, has the Proposed

Insured used any form of tobacco or nicotine

replacement therapy? ■ Yes ■ No

Name of Policyowner (First, Middle Initial, Last) Relationship to Proposed Insured

Policyowner Address (Street, City, State, Zip) Phone No. Social Security No.

Sex

■ Male ■ Female

Date of Birth Age E-mail Citizenship Country

OWNER (Complete only if Owner/Applicant is different from Proposed Insured)

4. In the past 2 years, has the Proposed Insured been diagnosed with, been treated for or advised by a

physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell

skin cancer)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

3. In the past 12 months, has the Proposed Insured been:

(a) advised by a physician to have a surgical operation, diagnostic testing other than for routine screening

purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not

been done or for which results are not known? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind? . .

■ Yes ■ No

1. Is the Proposed Insured currently:

(a) bedridden or conﬁned to any hospital, nursing home, long-term care facility or skilled nursing facility;

or receiving or been advised to receive care in a nursing home, hospice care, or home health care? . . . .

(b) requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating,

toileting, getting in and out of a chair or bed, or control of bowel or bladder problems? . . . . . . . . . . . . . . . . . . .

(c) requiring any of the following (other than for fractures, bone or joint surgery, including replacement):

wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)? . . . . . .

■ Yes ■ No

2. Has the Proposed Insured ever been:

(a) diagnosed as having Acquired Immune Deﬁciency Syndrome (AIDS), AIDS Related Complex (ARC),

or Human Immunodeﬁciency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for

AIDS, ARC, or HIV by a physician or heath care provider? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for

Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou

Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure,

Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or

diagnosed with End Stage Renal Disease or requiring dialysis?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(d) advised to receive or have received an organ or bone marrow transplant?. . . . . . . . . . . . . . . . . . . . . . . . .

(e) diagnosed by a physician or health care provider as having a terminal medical condition that is

expected to result in death within the next twelve 12 months?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

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5. Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician

or health care provider to seek treatment for:

(a) Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy

(kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)? . . . . . . . . . . . . . . . . . . . . . . . . .

(b) Hepatitis C? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis,

Emphysema, or Sarcoidosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

Part Two IF THE PROPOSED INSURED ANSWERS “YES” TO ANY QUESTION IN PART TWO, THAT PERSON IS ELIGIBLE

ONLY FOR THE GRADED BENEFIT PRODUCT.

6. In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by

a physician or health care provider to seek treatment for:

(a) Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)? . . .

(b) Chronic Kidney Disease, Systemic Lupus or Scleroderma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis? . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

7. In the past 2 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by

a physician or health care provider to seek treatment for:

(a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy,

irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement? . . . . . . . . . . . . . . . .

(b) Stroke or Transient Ischemic Attack (TIA)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

8. In the past 2 years, has the Proposed Insured:

(a) been convicted of or currently awaiting trial for a felony?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) been treated for or advised to have treatment for alcohol or drug abuse or convicted more than once

of reckless driving or driving under the inﬂuence of drugs or alcohol?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) used unlawful drugs in any form or abused or misused prescription drugs? . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

9. In the past 2 years, has the Proposed Insured been hospitalized by a physician or health care provider

for any mental or nervous disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

■ Yes ■ No

10. In the past 12 months, has the Proposed Insured consulted a physician for chronic cough,

unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding?. . . . . . .

■ Yes ■ No

NOTE: If the Proposed Insured answers all above questions “No”, that person is eligible for the Level Beneﬁt Product.

OPTIONAL COMMENTS (Not Required) - Provide any additional information available.

Question

Number

Details to Underwriting Questions

(Diagnosis, Dates, Durations, Medications, Dosages)

ICC14L643A

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Authorization: I authorize any medical provider, hospital, clinic, pharmacy, pharmacy benefit manager, or other medical care

facility, MIB, Inc. (MIB), state department of motor vehicles and other entities processing motor vehicle records, insurance

companies or consumer reporting agencies to release information about me or my health, such as, medical history, including

the presence of HIV infection, AIDS or ARC, mental or physical condition, prescription drug records, drug or alcohol use, driving

record or insurance claims information, to United of Omaha Life Insurance Company (“United of Omaha”). The information will

be used to determine my eligibility for insurance or to resolve or contest any issues of incomplete, incorrect or misrepresented

information on this application that may arise. I also authorize United of Omaha to disclose information to MIB. I understand

that my information received by MIB may be disclosed, upon request, to another member company with whom I apply for life

or health insurance or to whom I may submit a claim for benefits. If the person or entity to whom information is disclosed is

not a health care provider or health plan subject to federal privacy regulations, the information may be redisclosed without

the protection of the federal privacy regulations. This authorization is valid for 24 months from the date signed. I may refuse

to sign this authorization but if I refuse, the insurance I am applying for will not be issued. I may revoke this authorization at

any time by written notice to the address below. This revocation is limited to the extent that United of Omaha has taken action

in reliance on the authorization or the law allows United of Omaha to contest the issuance of the policy or a claim under the

policy. I will receive a copy of this authorization.

Agreement: To the best of my knowledge and belief, I represent the information above is true and complete. Any incorrect or

misleading answers may void this application and any issued policy effective the issue date. Unless otherwise provided under

a conditional receipt, I understand that no insurance shall take effect until all outstanding application requirements have been

received, a policy is issued and the first premium is received by United of Omaha during the Proposed Insured’s lifetime. The

issue date of the policy will be the date shown on the policy, even though coverage may not become effective until a later date.

You must immediately notify United of Omaha if there has been a change in the Proposed Insured’s health or habits that will

change any statement or answer to any question in the application as of the date the policy is delivered. No policy of any kind

will be in effect if the Proposed Insured dies or is otherwise ineligible for the insurance for which they applied. No producer

can waive or change any receipt or policy provision or agree to issue any policy.

PLAN INFORMATION

BENEFICIARY (If more space is needed, list on a separate sheet)

OTHER COVERAGE INFORMATION

AUTHORIZATION and AGREEMENT

Plan:

■ Level Benefit Product uu ■ Graded Benefit Product

Amount Applied For $ ___________________ yy

Rider: (Only if selecting Level Beneﬁt Product)

■ Accidental Death Rider

Payment Mode:

■ Annual ■ Semiannual ■ Quarterly ■ Monthly (Automated Bank Account Withdrawal)

Modal Premium $________________ Collected Premium $_______________

Primary Beneﬁciary

Relationship to Insured Date of Birth

Contingent Beneﬁciary Relationship to Insured Date of Birth

1. Does the Proposed Insured have any pending applications or existing life insurance or annuity contracts

with the company or any other company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

2. Is the insurance applied for intended to replace or change any life insurance or annuity contract in

force with the company or any other company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

If “Yes” to questions #1 or #2, please give details below. If more space is needed, list on a separate sheet.

Company Proposed Insured Face Amount To be Replaced or Converted?

■ Yes ■ No

ICC14L643A

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Fraud Warning: Any person who knowingly presents a false statement in an application for insurance may be guilty of

a criminal offense and subject to penalties under state law.

If applying for the Graded Beneﬁt Product: I understand that a reduced death beneﬁt amount is payable during the ﬁrst two

policy years if death results from sickness or other natural causes. The full face amount is payable during the ﬁrst two policy

years if death results from an accident.

Signed at:___________________________________________________

City State

____________________________________________________________ Date: ___________________________________

Signature of Proposed Insured

__________________________________________________________________ Date: _______________________________________

Signature of Applicant/Owner/Trustee (if Other Than Proposed Insured)

Producer Statement:

By signing below, I/we, the Producer(s), hereby agree that I/we know of nothing detrimental to the risk that is not recorded in this application.

1. I/We certify that, during an interview with the Proposed Insured, I/we asked each question exactly as written and recorded

the answers provided by the Proposed Insured(s) completely and accurately. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

2. Do you, the Producer(s), have any reason to believe the policy applied for has replaced or will replace any

insurance policy or annuity contract in force with the company or any other company? . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

3. Has the Proposed Insured informed you, the Producer(s), that he/she has any pending or existing life

insurance or annuity contracts with the company or any other company?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

(If the above questions are answered “Yes,” fulfill all state and company requirements.)

4. Are you related to the Proposed Insured or Owner? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

If “Yes,” state relationship ___________________________________________________________________________________

5. How long have you known the Proposed Insured? ____________________________________

6. How long have you known the Proposed Owner? _____________________________________

7. Previous residence of Proposed Insured for the past five years.

Street Address City State Zip Code

8. I/We conducted said interview in person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes ■ No

If “No,” please explain _________________________________________________________________________________

_____________________________________ ____________________________ ____________________ _______________

Signature of Producer #1 Producer E-mail Production Number Date

_____________________________________ ____________________________ ____________________ _______________

Signature of Producer #2 Producer E-mail Production Number Date

_________________________________ __________________________________ __________________________________

Print Producer #1 Name Print Producer #2 Name Agency Name

ICC14L643A

Producer Report

1 Was a Personal Health Interview (PHI) conducted by Apptical Corporation as a part of the application process?..... Yes No

If Yes, please provide the PHI number__________________________________________________

2 List any additional information or comments below:

______________________________________________________________________________________________________

L8532_0615

L8473_0417

PAYMENT AUTHORIZATION FORM

Name of payor as shown on bank account: ______________________________

If premium is NOT paid by Proposed Insured/Insured, indicate the bank account owner's relationship to Proposed Insured/

Insured by selecting one of the following. (Additional documentation may be required)

Employer Living Trust

Business owned by Proposed Insured/Insured or spouse Other ____________________________________

Power of Attorney or legal guardian

Complete this form only when authorizing a bank account for withdrawal for a premium payment.

I authorize United of Omaha Life Insurance Company to initiate any initial or recurring preauthorized electronic transfers from my

account. I understand the amounts may vary as premium shortages may result from a variety of reasons, including underwriting

adjustments. This authorization will be effective until I give you at least three business days notice to cancel. If notice is given

verbally, United of Omaha Life Insurance Company may require written confirmation within 15 days after my verbal notice.

Date ________________________ X ______________________________________________________

Mo./Day/Yr. Payor Authorized Signature as Shown on Account

Payor Authorization

1. Account Type (check one): Checking Savings

2. Name of Financial Institution: ________________________________________________________________________

3. Complete information below or attach a voided check here.

Bank Routing Number: ___________________________ Bank Account Number: ___________________________

(Do not use Debit/Credit Card numbers)

Payor Account Information

Memo __________________ Signed By: ______________________________________

Bank Routing

Number

Bank Account

Number

{

Check Number (if shown at bottom, may

be shown before or after the account #)

|

:123456789:

|

12345678

||



1234

||



{

Initial Premium Payment (select only one option) Amount Quoted $ ______________________

Deduct premium immediately upon approval/issue

Deduct initial premium on or after: _______/_______/_______ (Please Note: If the policy issue is after the date selected, the

initial payment will be deducted on the date the policy is issued or all delivery requirements are received.)

Check collected and mailed to Mutual of Omaha

Money will be deducted from your account as stated above. The first deduction may occur on a date different than the ongoing

payments. Depending on the amount of time elapsed between the policy date and the date the policy is issued, the amount of

the first deduction may exceed one regular payment amount. We CANNOT establish electronic payments from foreign banks.

Proposed Insured/Insured: ____________________________ Policy Number(s) if known: _____________________________

United of Omaha Life Insurance Company

Mutual of Omaha Plaza, Omaha, NE 68175, 402-342-7600

Ongoing Automatic Monthly Premium Payments (Once a Month)- Select only one option

Choose the day payments will be deducted every month from your bank account:

(1st through the 28th or Last Day of every month) ______________________

-OR-

Choose the week and weekday that payments will be deducted every month from your bank account:

(For example, 3rd Wednesday of every month)

Week (1st, 2nd, 3rd, 4th, Last) ______________________ Weekday (Mon, Tue, Wed, Thu, Fri) _______________________

Each month, payments will be automatically deducted from the account below on the day selected above. If no date is selected,

premiums will be deducted on the policy date (which is determined at the time the policy is issued and can be found within

the policy). Ongoing deductions will begin once the policy is issued. If the scheduled deduction date lands on a weekend or

holiday, the payment will process on the following business day.

Payor Information

Payment Information For Ongoing Payments- Automatic Bank Account Deduction

Payment Information For The First Payment- Can Be Different Than The Ongoing Payments

ICC13L627A PLEASE SUBMIT TO HOME OFFICE 40

Conditions

Beneﬁt

This Receipt and any coverage provided hereunder will END on the earliest of the following dates:

1 60 days from the date of this Receipt; or

2 The date we deliver the policy applied for to the Applicant/Owner and all delivery requirements have been

completed; or

3 The date we mail you a letter notifying you that we: (a) are unable to approve the requested coverage at the

risk class applied for; or (b) have declined to issue you a policy; or (c) will not provide conditional receipt

coverage; or

4 The date the Applicant/Owner withdraws the application for insurance.

End Date

Conditions under which a benefit may be payable under this Receipt prior to policy delivery:

1 The amount received via check or authorized electronic transaction with the application is sufficient to pay: (a)

the first premium of a fixed premium plan at the mode applied for; or (b) the first planned periodic premium

on a flexible premium plan; and

2 Each person proposed for insurance is, as of the application date, eligible for the exact policy applied for,

according to the underwriting standards of United then in effect, without modification of the plan, premium

rate, benefits, class and amounts of coverage applied for; and

3 To the best knowledge and belief of those signing the application, all the statements and answers in the

application are true and complete when made; and

4 All parts of the application, and if required, exams, supplements to the application, questionnaires and

amendments to the application, are completed and received by United.

If a Proposed Insured dies by suicide or self-inflicted injury, while sane or insane, United will not be liable under

this Receipt except to return any payment paid with the application.

This Receipt does not limit United in applying its underwriting standards to the application nor does this Receipt

limit or waive any rights under any life insurance policy issued. If United rejects or declines the application,

United will refund the applicant any premium paid with the application.

I/We have read and received a copy of this Receipt and understand and agree to all of its terms. I/We verify the

above answers are true and complete to the best of my/our knowledge and belief. I/We understand that the

Producer has no authority to change the terms of this Receipt.

_________________________________________________ ______________________________________________

Signature of Proposed Insured Date

_________________________________________________ ______________________________________________

Signature of Other Proposed Insured Date

_________________________________________________ ______________________________________________

Signature of Applicant/Owner (if other than Proposed Insured) Date

Payment Method: Check ■ Electronic Transaction Authorization ■ Amount remitted/authorized $_______________

I/We agree that I/We am/are not authorized to change or waive the terms of this Receipt and represent that I/We

have not attempted to do so. I/We have read and explained the terms of this Receipt to the Proposed Insured(s)

and the Applicant/Owner. I/We have left a copy with the Applicant/Owner.

_________________________________________________ _____________________________________________

Signature of Producer Date

_________________________________________________ _____________________________________________

Signature of Producer Date

Signatures

Conditional Receipt (“Receipt”)

United of Omaha Life Insurance Company (“United”, “we”), Mutual of Omaha Plaza, Omaha, NE 68175

If any proposed insured dies while coverage under this Receipt is in effect, we will pay to the beneﬁciary(ies) named

in the application the amount described in the section below entitled “Beneﬁt”.

Date of Receipt:___________________

For purposes of this Receipt, the benefit under this Receipt is an amount equal to the lesser of: (1) the amount of

the death benefit that would be payable in the first policy year under the policy as applied for in the application;

or (2) $40,000 minus the amount of any insurance on the Proposed Insured’s life under any other temporary

insurance agreements and/or conditional receipts. In no event will the amount of the Conditional Receipt

benefit under this Receipt exceed $40,000.

Applicant Copy L

United of Omaha Life Insurance Company

A Mutual of Omaha Company

ACCELERATED DEATH BENEFIT RIDER DISCLOSURE

The benefit received under the rider may be taxable. Receipt of the accelerated death benefit may adversely affect

your eligibility for Medicaid or other government benefits or entitlements. You should consult your personal tax

advisor or the Social Security Administration before requesting the benefit.

This disclosure is a brief description of the Accelerated Death Benefit for Terminal Illness or Nursing Home

Confinement Rider and its effects on your policy. This disclosure is not an insurance contract, but only a summary

of the coverage provided by the rider. There is no premium or cost of insurance charge for the rider.

BENEFIT DESCRIPTION

While the rider is in force and the insured has a terminal illness or is under nursing home confinement, you may

elect to receive the accelerated death benefit before the insured dies. A terminal illness is a medical condition that

will result in the insured’s death within 12 months. Nursing home confinement means that the insured has been

confined to a nursing home for at least 90 consecutive days and is expected to remain confined for the remainder

of his or her life. A physician must certify that the insured has a terminal illness or is under nursing home

confinement.

The amount available for the accelerated death benefit is your policy’s death benefit. You may receive the

accelerated death benefit only once.

For a terminal illness, we will reduce the accelerated death benefit by 6%.

For nursing home confinement, we will reduce the accelerated death benefit by the nursing home confinement

factor. The nursing home confinement factor varies by policy year as shown in the rider. We will also reduce the

accelerated death benefit by a $100 charge and by the amount of any loans and unpaid premiums.

EFFECT OF THE ACCELERATED DEATH BENEFIT ON THE POLICY

The rider will terminate when the accelerated death benefit is paid.

NOTE: If the policy is issued as a graded death benefit, the accelerated death benefit is not available.

Acknowledgment

I acknowledge receipt of this disclosure form.

_________________________________________________ _____________________

Applicant/Owner Signature Date

I have provided this disclosure form to the applicant/owner.

_________________________________________________ _____________________

Producer Signature Date

Company’s Copy L8517

Company’s Copy M28704

M28704

Authorization for Release of Information

to My Insurance Agent, Agency and/or

Authorized Third Party Vendor

I authorize Mutual of Omaha Insurance Company and their affiliated companies (Mutual), or

authorized third party vendor, to disclose personal and medical information about me to my insurance

agent and/or agency.

Information that Mutual or an authorized third party vendor may disclose includes medical

information and other personal information as it relates to actions Mutual may have taken based on this

information, such as charging me a higher premium for my insurance, changing benefits to something

other than I applied for or declining my application for insurance.

The information will be used to help me with the insurance application process or to find other

insurance coverage options.

I understand that if the person or entity that receives the above information is not covered by federal

privacy regulations, the information described above may be re-disclosed by such person or entity and

will likely no longer be protected by the federal privacy regulations.

I understand that I may refuse to sign this authorization. If I refuse to sign it will not affect the issuance

of the insurance for which I am applying.

Unless revoked earlier, this authorization will remain in effect for 24 months from the date I sign it. I

understand that I may revoke this authorization at any time, by written notice to: Mutual of Omaha,

ATTN: Individual Underwriting, 3300 Mutual of Omaha Plaza, Omaha, NE 68175.

I realize that my right to revoke this authorization is limited to the extent that Mutual has taken action

in reliance on the authorization.

I understand that I will receive a copy of the authorization.

✍

X

✍

X

Signature of Applicant A Date Signature of Applicant B Date

Mutual of Omaha Insurance Company

United of Omaha Life Insurance Company

Companion Life Insurance Company

IMPORTANT DOCUMENTS

LEAVE THE FOLLOWING REMAINING PAGES WITH CLIENT(S)

As part of the application process, the applicant has signed multiple

forms. Applicant copies of these forms and notifications on the

following pages are to be left with applicant(s).

CLIENT

FORMS

ICC13L627A APPLICANT COPY 40