Life Insurance Health

Location:

Posted:

June 06, 2024

Resume:

CONSENT TO ELECTRONIC SIGNATURES AND DELIVERY OF DOCUMENTS

Mutual of Omaha Insurance Company, on behalf of itself and its affiliates, Companion Life Insurance Company, Omaha Health Insurance Company, Omaha Insurance Company, Omaha Supplemental Insurance Company, United of Omaha Life Insurance Company and United World Life Insurance Company, is required to obtain your consent to use electronic signatures and to deliver insurance related documents electronically to you whether through the internet, email, web, text, instant message, digital media, or the like. If you consent to electronic delivery as described in this Consent, you will be consenting to electronic delivery of all documents we may deliver to you relating to the insurance policies you have with us, or might apply for with us, to the extent permitted by law. From time to time, we may send these documents to you in pdf, text or html format as an attachment or through a secure portal or web page via a hyperlink to the email, phone number, or instant message you provide us. We will notify you verbally or via an email, text message, instant message or similar communication to alert you as to how you may access the documents. We may still send some documents to you in paper at your regular mailing address. For this reason, it is important that you inform us of any changes to your regular mailing address. Your consent is purely voluntary. However, if you do not provide your consent, we will not be able to complete your transactions electronically. Any documents delivered electronically will be provided to you in paper upon request at no charge.

By agreeing below and providing us with an email address or other contact information for delivery of documents, you consent that all documents may be provided electronically. You are responsible to update the email address or other contact information on file with us if it changes. If we notify you that information is available to review on a website or secure portal, you agree that delivery of the information is deemed completed upon receipt of such communication.

If you wish to (1) change your email address or other contact information; (2) withdraw consent to receive electronic delivery of future information and other records; or (3) request a paper copy of the information, please contact us at 1-800-***-****.

The computer hardware and software you used to access the Internet, along with an email address and phone number is all you will need to access the documents provided to you in electronic form. Some information may be provided in pdf format. You agree that you can access the internet, open, view and save materials sent in pdf format. You should retain a copy of these materials for future reference by printing or saving the documents.

BY CLICKING ‘I AGREE’ YOU AGREE TO RECEIVING RECORDS ELECTRONICALLY AS DESCRIBED ABOVE. Please read this notice carefully and print or download a copy for your files. 465557

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United of Omaha Life Insurance Company – Notice of Information Practices In the course of properly underwriting and administering your insurance coverage, 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. Upon request, 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, where applicable. You also have the right to seek correction of personal information you believe to be inaccurate. In the event of an adverse underwriting decision, our Company will provide in writing the specific reason for the underwriting decision. 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: UNITED OF OMAHA LIFE INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175. L8303

MIB, Inc. Pre-Notice

Information regarding your insurability will be treated as conﬁdential. United of Omaha Life Insurance Company, 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-***-**** (TTY 866-***-****). 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 Park, Suite 400, Braintree, MA 02184-8734.

United of Omaha Life Insurance Company, 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. Information for consumers about MIB, Inc. may be obtained on its website at www.mib.com. L7941

ICC23L681A PLEASE SUBMIT ALL PAGES 1

PROPOSED INSURED

Part One IF THE PROPOSED INSURED ANSWERS “YES” TO QUESTIONS 2-5 IN PART ONE, THAT PERSON IS NOT ELIGIBLE FOR ANY COVERAGE UNDER THIS APPLICATION.

INDIVIDUAL LIFE INSURANCE APPLICATION

UNDERWRITING

First Name MI Last Name Suffix Q Male

Q Female

Height Weight Social Security No.

Home Address Street Apt/Ste# City State Zip State

of Birth

Date of Birth

Phone No. E-mail Driver’s License No. Driver’s License State Are you a U.S. citizen or legal permanent resident of the United States? Q Yes Q No

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

In the past 12 months, has the Proposed

Insured used tobacco or any product containing

nicotine Q Yes Q No First Name MI Last Name Suffix Relationship to Proposed Insured Street Address Apt/Ste# City State Zip Phone No. Social Security No. Q Male Q Female

Date of Birth E-mail Citizenship Country

OWNER (Complete only if Owner/Applicant is different from Proposed Insured) 5. In the past 2 years, has the Proposed Insured been diagnosed with, been treated for or advised by a member of the medical profession to receive treatment for any form of cancer (except basal or squamous cell skin cancer)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No 4. In the past 12 months, has the Proposed Insured been:

(a) advised by a member of the medical profession 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 member of the medical profession as having heart disease or heart surgery of any kind? . . . Q Yes Q No

Q Yes Q No

1. Has the Proposed Insured ever been diagnosed by a member of the medical profession or been tested positive for Human Immunodeficiency Virus (AIDS Virus) or Acquired Immune Deficiency Syndrome (AIDS)? Q Yes Q No 2. 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 by a member of the medical profession 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, advised by a member of the medical profession to use oxygen equipment to assist breathing (excluding use for sleep apnea) or defibrillator?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

Q Yes Q No

3. Has the Proposed Insured ever (i) been diagnosed with, (ii) received treatment for, or (iii) been advised by a member of the medical profession to seek treatment for:

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

(MDS), Lou Gehrig’s Disease (ALS), Hydrocephalus, Muscular Dystrophy, Quadriplegia, Paraplegia, Down Syndrome, Intellectual Developmental Disorder, Congestive Heart Failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) insulin shock, diabetic coma, amputation due to diabetic complications, End Stage Renal Disease or requiring dialysis?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) an organ or bone marrow transplant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(d) a terminal medical condition that is expected to result in death within the next twelve (12) months?. . . . . . . Q Yes Q No

Q Yes Q No

ICC23L681A

3300 Mutual of Omaha Plaza

Omaha, Nebraska 68175

739***-*********

5244190

560 S 6th St Cottage Grove, OR 97424-2782

09/21/1975

****************@*****.***

Josh M Hollowell 5' 7" 150

512-***-****

***-**-****

ICC23L681A PLEASE SUBMIT ALL PAGES 2

6. Has the Proposed Insured ever (i) been diagnosed with, (ii) received treatment for, or (iii) been advised by a member of the medical profession to seek treatment for:

(a) Diabetes before age 45?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) Diabetes at any age with complications or history of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve), Peripheral Vascular Disease (PVD or PAD), Coronary Artery Disease (CAD) or Stroke? . . .

(c) Hepatitis C? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(d) Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Sarcoidosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

Q Yes Q 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.

7. In the past 4 years, has the Proposed Insured: (i) been diagnosed with, (ii) received treatment for, or (iii) been advised by a member of the medical profession to seek treatment for:

(a) Cancer, Leukemia, or any other internal cancer or Melanoma (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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

Q Yes Q No

8. In the past 2 years, has the Proposed Insured: (i) been diagnosed with, (ii) received treatment for, or (iii) been advised by a member of the medical profession to seek treatment for:

(a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, Pacemaker or Valvular Heart Disease with surgical repair or replacement? . . . . . . .

(b) Stroke or Transient Ischemic Attack (TIA)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

Q Yes Q No

9. 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 by a member of the medical profession to have treatment for alcohol or drug abuse, convicted of driving under the influence of drugs or alcohol or convicted more than once of reckless driving?. . . . . .

(c) used unlawful drugs in any form (other than marijuana) or abused or misused prescription drugs? . . . . . . . . Q Yes Q No

Q Yes Q No

10. In the past 2 years, has the Proposed Insured been hospitalized by a member of the medical profession for any mental or nervous disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No 11. In the past 12 months, has the Proposed Insured been diagnosed or treated by a member of the medical profession for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q 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) ICC23L681A

UNDERWRITING, Continued

PLAN INFORMATION

Plan:

Q Level Benefit Product Q Graded Benefit Product

Amount Applied For $

Rider: (Only if selecting Level Benefit Product)

Q Accidental Death Rider

Modal Premium $ Collected Premium $ Name & Address of Payor (if other than Proposed Insured/Owner) Relationship of Payor (if other than Proposed Insured/Owner) PREMIUM INFORMATION

Premium Method Q Direct Bill Q Bank Draft (Complete Payment Authorization Form) Q Other(Please Explain) Frequency of Modal Premium Q Monthly (Bank Draft Only) Q Annual Q Semi-Annual Q Quarterly

$5,000

ICC23L681A PLEASE SUBMIT ALL PAGES 3

Authorization: I authorize any medical provider, hospital, clinic, pharmacy, pharmacy benefit manager, or other medical care facility, MIB, LLC (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 information regarding communicable or infectious conditions or 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. This time limit complies with the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. 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 United of Omaha. 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: I represent the information above is true and complete to the best of my knowledge and belief. 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. 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) BENEFICIARY (If more space is needed, list on a separate sheet) OTHER COVERAGE INFORMATION

AUTHORIZATION and AGREEMENT

Primary Beneficiary First Name MI Last Name Suffix Relationship to Insured Date of Birth Contingent Beneficiary First Name MI Last Name Suffix 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q 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?

Q Yes Q No

ICC23L681A

Producer Statement

1. 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?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

(If the above questions are answered “Yes,” fulfill all state and company requirements.) 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? . . . . . . . . . . . . . . . . . . . Q Yes Q No 3. Did you, the Producer(s), give the Proposed Insured the MIB, LLC Pre-Notice, the Notice of Information Practices (if applicable) and the Life Insurance Buyer’s Guide?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No If “No,” please explain 4. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Q Yes Q No 5. I/We conducted said interview in person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No If “No,” please explain 6. (a) Are you the Proposed Insured or Owner?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No

(b) Are you related to the Proposed Insured or Owner? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q No If “Yes,” state relationship 7. How long have you known the Proposed Insured? 8. How long have you known the Proposed Owner? Print Producer #1 Name Producer E-mail Production Number Agency Name Signature of Producer #1 Date

Print Producer #2 Name Producer E-mail Production Number Agency Name Signature of Producer #2 Date

PLEASE SUBMIT ALL PAGES 470572

470572

***************@*****.***

CARLEY N ARMITAGE 1129200 FAMILY FIRST LIFE

Producer Contact Information

Office Phone Number: 217-***-****

Email Address: ***************@*****.***

Complete for all authorized signators on the policy. Owner

Name

Address

City State ZIP

Home Phone Number

Client ID/Social Security Number

Age Last Birthday

Marital Status Married ■ Single ■ Widowed ■ Divorced ■ Occupation

Dependent Information

Number of dependents

Ages of dependents

Financial Information

Annual Household Income

Liquid Net Worth (Excluding Residence)

Federal Tax Bracket

Years of Investment Experience

Investment Product Years Currently Own?

Stocks/Stock Mutual Funds

Bonds/Bond Mutual Funds

Annuities

Life Insurance

Certificates of Deposit

Other

United of Omaha Life Insurance Company

A Mutual of Omaha Company

Life Insurance Suitability Information

We appreciate your interest in a life insurance policy from United of Omaha Life Insurance Company. Your state requires that life insurance providers ask for information that will help determine whether the life insurance policy is suitable for your insurance objectives, financial situation, needs, age and other relevant information.

■ I decline to complete the form. I assert that the life insurance policy is suitable for my needs and insurance objectives. I have adequate income or available liquid assets to meet my financial situation and needs without using the money I am paying for in this policy. (All owners must sign in the “Signatures” space at the bottom of the page.) Joint Owner

Name

Address

City State ZIP

Home Phone Number

Client ID/Social Security Number

Age Last Birthday

Marital Status Married ■ Single ■ Widowed ■ Divorced ■ Occupation

Amount/Type of Product Being Purchased

■ Term Life $ ■ Permanent Life $

■ Other $

Goals of this Product or Reason for Purchase

(Check all that apply)

■ Preservation of Capital ■ Education Planning

■ Wealth Accumulation ■ Charitable Giving

■ Future Income ■ Provide Inheritance (Death Benefit) Time Frame

When, if ever, do you anticipate withdrawing funds from this policy?

■ 1 Year or Less ■ 7-10 Years

■ 1-3 Years ■ 10 Years or More

■ 3-7 Years ■ Upon death (inheritance or charity)

L7229_0116

Signatures

I/We have adequate income or available liquid assets to meet my/our financial obligations and emergency expenses without using the money I am using to purchase this life insurance policy.

Owner's Signature Joint Owner's Signature

Agent’s Signature Agent’s Print Name

Note to Producer: This form is required for all insurance sales. It is also required in addition to all replacement requirements if the sale of this life insurance policy involves a replacement.

L7229_0116

CARLEY N ARMITAGE

Cottage Grove

560 S 6th St

OR 974242782

Josh M Hollowell

$5,000

Applicant Copy L

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

3300 Mutual of Omaha Plaza

Omaha, Nebraska 68175

Applicant Copy L

ACCELERATED DEATH BENEFIT RIDER DISCLOSURE

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

I acknowledge receipt of this disclosure form.

Applicant/Owner Signature Date

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

Applicant’s Copy L8517

Contact this candidate