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 1-800-775-6000.

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
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 866-692-6901 (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 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
 AIS BU4893138
3300 Mutual of Omaha Plaza
Omaha, Nebraska 68175

739160-151430933
INDIVIDUAL LIFE INSURANCE APPLICATION
PROPOSED INSURED
First Name MI Last Name Suffix Q
QMale Height Weight Social Security No.
Roberta S Coleman
X Female 5' 6" 194 292-56-3624
Q
Home Address Street Apt/Ste# City State Zip State Date of Birth
of Birth
155 Township Road 1163 Proctorville, OH 45669-8667
OH 09/25/1960

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

[email protected]
(740) 744-5433 Rl728963 OH

X Yes Q No
Are you a U.S. citizen or legal permanent resident of the United States? Q In the past 12 months, has the Proposed
(If “No”, you are not eligible for coverage.) Insured used tobacco or any product containing
nicotine ?...................................... Q Yes X
Q No

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

First Name MI Last Name Suffix Relationship to Proposed Insured

Street Address Apt/Ste# City State Zip Phone No. Social Security No.

Date of Birth E-mail Citizenship Country

Q Male Q Female

UNDERWRITING
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.
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 X
QYesQ
QNo
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, XNo
Q Yes Q
hospice care, or home health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b) requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, XNo
Q Yes Q
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 Q Yes Q X No
breathing (excluding use for sleep apnea) or defibrillator?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 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?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X No
Q Yes Q
(b) insulin shock, diabetic coma, amputation due to diabetic complications, End Stage Renal Disease or
requiring dialysis?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
(c) an organ or bone marrow transplant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
(d) a terminal medical condition that is expected to result in death within the next twelve (12) months?. . . . . . . XNo
Q Yes Q
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
XNo
ICC23L681A

procedure which has not been done or for which results are not known?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q
(b) diagnosed by a member of the medical profession as having heart disease or heart surgery of any kind? . . . XNo
Q Yes Q
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 QXNo
ICC23L681A PLEASE SUBMIT ALL PAGES 1
 AIS BU4893138
UNDERWRITING, Continued
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. 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?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
(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? . . . XNo
Q Yes Q
(c) Hepatitis C? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X No
Q Yes Q
(d) Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis,
Emphysema, or Sarcoidosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
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)? . . XNo
Q Yes Q
(b) Chronic Kidney Disease, Systemic Lupus or Scleroderma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
(c) Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
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? . . . . . . . XNo
Q Yes Q
(b) Stroke or Transient Ischemic Attack (TIA)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
9. In the past 2 years, has the Proposed Insured:
(a) been convicted of or currently awaiting trial for a felony?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q X No
(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?. . . . . . Q Yes Q XNo
(c) used unlawful drugs in any form (other than marijuana) or abused or misused prescription drugs? . . . . . . . . Q Yes Q XNo
10. In the past 2 years, has the Proposed Insured been hospitalized by a member of the medical profession for
XNo
any mental or nervous disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q
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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XNo
Q Yes Q
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 Details to Underwriting Questions
Number (Diagnosis, Dates, Durations, Medications, Dosages)

PLAN INFORMATION
Plan: Rider: (Only if selecting Level Benefit Product)
X
Q Level Benefit Product QGraded Benefit Product Q Accidental Death Rider
Q
$20,000
Amount Applied For $ ___________________
PREMIUM INFORMATION
Premium Method X
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 X
Q Quarterly
$233.37
ICC23L681A

Modal Premium $________________ Collected Premium $______________

Name & Address of Payor (if other than Proposed Insured/Owner)_____________________________________________________________
Relationship of Payor (if other than Proposed Insured/Owner)____________________________________________________________

ICC23L681A PLEASE SUBMIT ALL PAGES 2

 AIS BU4893138

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

Primary Beneficiary First Name MI Last Name Suffix Relationship to Insured Date of Birth
Bruce W Coleman Spouse/Civil Union Partner 05/29/1960

Contingent Beneficiary First Name MI Last Name Suffix Relationship to Insured Date of Birth

OTHER COVERAGE INFORMATION

1. Does the Proposed Insured have any pending applications or existing life insurance or annuity contracts
X No
with the company or any other company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q
2. Is the insurance applied for intended to replace or change any life insurance or annuity contract in
X No
force with the company or any other company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Q Yes Q
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

Q Yes Q No

QYes
Q Q
QNo

AUTHORIZATION and AGREEMENT

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.
Proctorville OH
Signed at:___________________________________________________
City State
ICC23L681A

eSigned by Roberta S Coleman 10/02/2024 at 19:46:15 GMT

________________________________________________________________ Date: ___________________________________
Signature of Proposed Insured
eSigned by Roberta S Coleman 10/02/2024 at 19:46:15 GMT
_________________________________________________________________________ Date: _______________________________________
Signature of Applicant/Owner/Trustee (if Other Than Proposed Insured)

ICC23L681A PLEASE SUBMIT ALL PAGES 3

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? _____________________________________

[email protected]

ANNA BRICKEY 0776842 NORTH AMERICAN SENIOR BENEFITS, LLC

_____________________________________ ____________________________ ____________________ ______________________
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
470572

PLEASE SUBMIT ALL PAGES 470572

 AIS BU4893138

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–‘™Š‘‹ˆ‘”ƒ–‹‘‹•†‹• Ž‘•‡†‹•‘–ƒŠ‡ƒŽ–Š ƒ”‡’”‘˜‹†‡”‘”Š‡ƒŽ–Š’Žƒ•—„Œ‡ ––‘ˆ‡†‡”ƒŽ’”‹˜ƒ ›
”‡‰—Žƒ–‹‘•ǡ–Š‡‹ˆ‘”ƒ–‹‘ƒ›„‡”‡†‹• Ž‘•‡†™‹–Š‘—––Š‡’”‘–‡ –‹‘‘ˆ–Š‡ˆ‡†‡”ƒŽ’”‹˜ƒ ›”‡‰—Žƒ–‹‘•Ǥ
Š‹•ƒ—–Š‘”‹œƒ–‹‘‹•˜ƒŽ‹†ˆ‘”ʹͶ‘–Š•ˆ”‘–Š‡†ƒ–‡•‹‰‡†ǤŠ‹•–‹‡Ž‹‹– ‘’Ž‹‡•™‹–Š–Š‡–‹‡Ž‹‹–ǡ‹ˆ
ƒ›ǡ’‡”‹––‡†„›ƒ’’Ž‹ ƒ„Ž‡Žƒ™‹–Š‡•–ƒ–‡™Š‡”‡–Š‡’‘Ž‹ ›‹•†‡Ž‹˜‡”‡†‘”‹••—‡†ˆ‘”†‡Ž‹˜‡”›Ǥ ƒ›”‡ˆ—•‡
–‘•‹‰–Š‹•ƒ—–Š‘”‹œƒ–‹‘„—–‹ˆ ”‡ˆ—•‡ǡ–Š‡‹•—”ƒ ‡ ƒƒ’’Ž›‹‰ˆ‘”™‹ŽŽ‘–„‡‹••—‡†Ǥ ƒ›”‡˜‘‡–Š‹•
ƒ—–Š‘”‹œƒ–‹‘ƒ–ƒ›–‹‡„›™”‹––‡‘–‹ ‡–‘‹–‡†‘ˆƒŠƒǤŠ‹•”‡˜‘ ƒ–‹‘‹•Ž‹‹–‡†–‘–Š‡‡š–‡––Šƒ–
‹–‡†‘ˆƒŠƒŠƒ•–ƒ‡ƒ –‹‘‹”‡Ž‹ƒ ‡‘–Š‡ƒ—–Š‘”‹œƒ–‹‘‘”–Š‡Žƒ™ƒŽŽ‘™•‹–‡†‘ˆƒŠƒ–‘
‘–‡•––Š‡‹••—ƒ ‡‘ˆ–Š‡’‘Ž‹ ›‘”ƒ Žƒ‹—†‡”–Š‡’‘Ž‹ ›Ǥ ™‹ŽŽ”‡ ‡‹˜‡ƒ ‘’›‘ˆ–Š‹•ƒ—–Š‘”‹œƒ–‹‘Ǥ

eSigned by Roberta S Coleman

10/02/2024 at 19:22:21 GMT

̴—–Š‘”‹œƒ–‹‘̴‘”†‹‰Ǧ ̴Ͳͳʹ͵
 AIS BU4893138

Producer Contact Information

Office Phone Number: 6784381324
Email Address: [email protected]
United of Omaha Life Insurance Company
A Mutual of Omaha Company AIS BU4893138
Request to Withdraw Funds by Credit Card
This form is intended as a request to debit your credit card.
Please complete initial and renewal information below.

The initial premium payment will be applied only if and when (a) the application has been approved for issue by
United of Omaha Life Insurance Company (“United of Omaha”) and (b) all policy requirements have been fulfilled.

Proposed Insured: _________________________________________________________________________________

Roberta S Coleman

Initial Premium Payment: X Credit Card $233.37

■ ****-****- 9928

Renewal Premium Payments: ■ Monthly Bank Service Plan X

■ Direct Bill

Credit Card Payment for Initial Premium Payment

United of Omaha is hereby requested and authorized to initiate a credit card transaction to be charged against the account
described below for the initial premium payment only. Renewal premium payments will be made either by direct billing or
monthly bank service plan (BSP).
___________________________________________________________________
Full Name (Print as it appears on card): Roberta S Coleman
Billing Address of Card Holder: 155
_______________________________________________________________________
Township Road 1163 Proctorville OH 45669-8667
Credit Type: X
■ Visa ■ MasterCard
Credit Card Reference Number: _______________________________________________________________________
350027380

☞ Please do not document the actual credit card number on this form.
eSigned by Roberta S Coleman
______________________________________________________________________ 10/02/2024 at 19:46:15 GMT
____________________
Authorized Signature as Shown on Account Date

L8306_CC
 AIS BU4893138
Roberta S Coleman

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
 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
Benefit

the death benefit that would be payable in the first policy year under the policy as applied for in the application;
or (2) $50,000 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 $50,000.

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,
Conditions

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 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
End Date

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.

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.
eSigned by Roberta S Coleman
_________________________________________________ 10/02/2024 at 19:46:15 GMT
______________________________________________
Signature of Proposed Insured Date

_________________________________________________ ______________________________________________
Signatures

Signature of Other Proposed Insured Date

eSigned by Roberta S Coleman
_________________________________________________ 10/02/2024 at 19:46:15 GMT
______________________________________________
Signature of Applicant/Owner (if other than Proposed Insured) Date

Payment Method: Check Q X

Electronic Transaction Authorization Q
QAmount 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

ICC13L627A PLEASE SUBMIT TO HOME OFFICE 50

 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
Benefit

the death benefit that would be payable in the first policy year under the policy as applied for in the application;
or (2) $50,000 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 $50,000.

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,
Conditions

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 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
End Date

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.

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.
eSigned by Roberta S Coleman
_________________________________________________ 10/02/2024 at 19:46:15 GMT
______________________________________________
Signature of Proposed Insured Date

_________________________________________________ ______________________________________________
Signatures

Signature of Other Proposed Insured Date

eSigned by Roberta S Coleman
_________________________________________________ 10/02/2024 at 19:46:15 GMT
______________________________________________
Signature of Applicant/Owner (if other than Proposed Insured) Date

Payment Method: Check Q X

Electronic Transaction Authorization Q
QAmount 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

ICC13L627A APPLICANT COPY 50

 AIS BU4893138

3300 Mutual of Omaha Plaza

Omaha, Nebraska 68175

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.

eSigned by Roberta S Coleman

_________________________________________________ 10/02/2024 at 19:46:15 GMT
_____________________
Applicant/Owner Signature Date

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

_________________________________________________ _____________________
Producer Signature Date

Company’s Copy L8517

Applicant Copy L
 3300 Mutual of Omaha Plaza
Omaha, Nebraska 68175

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.

eSigned by Roberta S Coleman

_________________________________________________ 10/02/2024 at 19:46:15 GMT
_____________________
Applicant/Owner Signature Date

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

_________________________________________________ _____________________
Producer Signature Date

Applicant’s Copy L8517

Applicant Copy L
 AIS BU4893138

eSignature Data Page

Proposed Insured HIPAA/Abandoned App

Roberta S Coleman

[email protected]

10/02/2024 at 19:22:21 GMT

2607:fb91:17ee:1e57:680f:d457:7d07:b2d5

Proposed Insured/Owner

Roberta S Coleman

[email protected]

10/02/2024 at 19:46:15 GMT

2607:fb91:1639:9655:512a:efea:9956:6bb1

Agent

ANNA BRICKEY

[email protected]