United of Omaha Life Insurance Company A Mutual of Omaha Company P.O. Box 3608 Omaha, Nebraska

Transcription

1 P.O. Bx 3608 Omaha, Nebraska Applicatin Submissin Checklist T United f Omaha Fr Medicare Supplement r Select Cverage OHIO THIS APPLICATION MUST BE USED TO WRITE UNITED OF OMAHA MEDICARE SUPPLEMENT/SELECT PRODUCTS Applicatin 1. Cmplete Plan Infrmatin Bx. 2. Refer t the Outline f Cverage fr plicy frms. 3. Answer all questins in full. 4. Sign and in all places indicated. 5. Be sure t leave all applicable frms with the prpsed insured. 6. See reverse side f this page fr additinal detailed infrmatin. Cllect Premium Amunt The full mdal premium is cllected at the time f applicatin. Calculate the premium based n age at time f applicatin. Fllw instructins n page 1 f Calculate Yur Premium frm (UC6582_0208) t calculate the premium. Cmplete the frm and return with the applicatin. Tbacc rates d nt apply during Open Enrllment r Guarantee Issue situatins. Prvide Client with Buyer s Guide Prvide Client with Outline f Cverage Cmplete Prducer Infrmatin page If applicable, cmplete the Authrizatin fr Electrnic Funds Transfer frm (ACH/BSP frm U7535_0409) and return with the cmpleted applicatin Withdrawal f the initial premium payment will ccur when the applicatin is prcessed. Prvide Client with Cnditinal Receipt signed by agent (if applicable), and prvide Client with Ntice f Infrmatin Practices Cmplete, sign and prvide client with cpy f the Authrizatin T Disclse Persnal Infrmatin (HIPAA frm U7566_0709). This frm is NOT a requirement if applying during an Open Enrllment r Guaranteed Issue Perid. Cmplete Replacement Ntice (U7563) and leave a cpy with the applicant (if applicable) Cmplete Medicare Select Plicy Disclsure Agreement (U7568) (if applicable) Please prvide additinal infrmatin and cmments in the space prvided n the applicatin. Nte: An interviewer may call t verify/cnfirm the infrmatin prvided n the applicatin. BROKERAGE ONLY Please list yur cmmissin cde in the bx n the first page f the applicatin. This will help avid delay in cmmissin payment. UAP617_OH_0709

2 There are tw parts t this applicatin: One part is the general applicatin. The ther part includes necessary administrative frms that yu will need at time f sale. 1. Applicatin Agent Cmpletes in Full: (please print) Plan Infrmatin Bx Plicy Frm Requested Effective Premium Cllected (Amunt) - Fllw instructins n page 1 f Calculate Yur Premium frm (UC6582_0208) t calculate the premium. Cmplete the frm fr s A & B (if applying) return with the applicatin. Initial Mde* (A=Annual, S=Semiannual, Q=Quarterly, B=Autmatic Funds Withdraw, r ACH=Autmated Clearing Huse) Renewal Premium (Amunt) Renewal Mde* (A=Annual, S=Semiannual, Q=Quarterly, r B=Autmatic Funds Withdraw) *Direct Mnthly billing nt available Sectin 1 General Infrmatin The Residence address and ZIP cde are indicated. Alternate address fr billing as indicated (when applicable). The applicant s current age at time f applicatin. The applicant s Scial Security number as indicated frm applicant s Scial Security Card. Fr applicants already cvered by Medicare, include applicant s Medicare number n the applicatin as indicated frm the applicant s Medicare Health Insurance Card. This number is required fr electrnic claim prcessing. If this number is nt available at time f applicatin, the applicant/agent must prvide this number by calling nce it is received. The applicant s current Height in feet and inches and Weight in punds. Sectins 2 and 3 Existing Cverage Infrmatin Please cmplete all questins in full. If the applicant is nt cvered by Medicare, indicate Eligibility and f Enrllment. List all individual and grup health plicies held by the applicant in the apprpriate sectin f the applicatin. If the applicant is replacing current cverage with this plicy, indicate the fllwing infrmatin. Name f Cmpany Issue Plicy/Certificate Number Terminatin/Disenrllment Plan Kind f Plicy NOTE: An interviewer may call t verify/cnfirm the infrmatin prvided n the applicatin. 2. Administrative Frms Prducer/Agent Infrmatin Be sure t include yur Scial Security number and cmmissin cde. NOTE: This infrmatin is necessary fr the underwriting prcess and cmmissin payment. Include yur telephne number, address and FAX number fr cntact purpses. Authrizatin fr Electrnic Funds Transfer by (ACH/BSP) If applicant chses t pay premium by ACH/BSP, cmplete this frm accurately and in its entirety and return with the applicatin. Optin A - Pay all premiums (1st & mnthly renewals) by ACH/BSP - DO NOT submit a check fr payment. Optin B - Pay 1st mnth by paper check & mnthly renewals by BSP - A check fr initial mnthly premium MUST be submitted with the applicatin Optin C - Pay 1st mnth by ACH & pay renewals by direct bill (mnthly direct billing is nt ffered) - DO NOT submit a check fr initial premium payment. Cnditinal Receipt and Ntice f Infrmatin Practices Cmplete and sign the receipt (if applicable), detach entire page and leave with applicant. Authrizatin T Disclse Persnal Infrmatin (HIPAA) If client is NOT applying during an Open Enrllment r Guaranteed Issue Perid, cmpleting the Authrizatin T Disclse Persnal Infrmatin frm IS a requirement. Please have the applicant read the frm, fill in required infrmatin, sign, date and leave a cpy f the cmpleted and signed frm with applicant. If client IS applying during an Open Enrllment r Guaranteed Issue Perid, cmpleting the Authrizatin T Disclse Persnal Infrmatin frm is NOT a requirement. Replacement Ntice cmplete if applicable Cmplete frm including signature and date. Leave a cpy with applicant (if applicable). State Specific Frms cmplete if applicable Be sure t include all state apprpriate frms.

3 Applicatin Fr Medicare Supplement Cverage Mgr./Cmmissin Cde (Required Field Fr Brkerage) District Sales Manager/Assc. Marketer Grup number (if applicable): Applicatin Reviewed By PLAN INFORMATION (t be cmpleted by Prducer) NOTE: Fr ALL sectins, ONLY cmplete the B infrmatin if t be insured. B Plicy Frm Plicy Frm Requested Effective Requested Effective Premium Cllected $ Premium Cllected $ Initial Mde A, S, Q, B r ACH Initial Mde A, S, Q, B r ACH Renewal $ Renewal $ Renewal Mde A, S, Q, B (mnthly nt available) Renewal Mde A, S, Q, B (mnthly nt available) 1. PLEASE READ THE FOLLOWING CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY. B Name (First/Middle/Last) Name (First/Middle/Last) Residence Address City Residence Address (if different frm s) City State ZIP State ZIP Mailing Address (if different frm residence address) City Mailing Address (if different frm residence address) City State ZIP State ZIP Hme Phne N ( ) (area cde) Current Age f Birth m day yr Male Female Scial Security N Medicare Health Insurance Card Number (if knwn) Address Hme Phne N ( ) (area cde) Current Age f Birth m day yr Male Female Scial Security N Medicare Health Insurance Card Number (if knwn) Address Height Ft In Weight Lbs Height Ft In Weight Lbs UA P.O. Bx 3608 Omaha, Nebraska

4 2. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS. 1. Have yu received a cpy f the Guide t Health Insurance fr Peple with Medicare and the Outline f Cverage? 2. Have yu used tbacc in any frm in the past 12 mnths? T the Best f Yur Knwledge: 1. Are yu cvered under Medicare Part A? If YES, what is yur Part A effective date? / B If NO, what is yur eligibility date? / B 2. Are yu cvered under Medicare Part B? If YES, what is yur Part B effective date? / B If NO, indicate date yu plan t enrll. / B 3. Did yu turn age 65 in the last six mnths? 4. Did yu enrll in Medicare Part B in the last six mnths? If YES, indicate yur effective date. / B B Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N If yu lst r are lsing ther health insurance cverage and received a ntice frm yur prir insurer saying yu were eligible fr guaranteed issue f a Medicare supplement insurance plicy, r that yu had certain rights t buy such a plicy, yu may be guaranteed acceptance in ne r mre f ur Medicare supplement plans. Please include a cpy f the ntice frm yur prir insurer with yur applicatin. PLEASE ANSWER ALL QUESTIONS. Please mark YES r NO with an X t the questins belw. 3. FOR YOUR PROTECTION, the Natinal Assciatin f Insurance Cmmissiners requests that we ask the fllwing questins abut insurance plicies r certificates yu may have. T the Best f Yur Knwledge: B 1. Are yu applying during a guaranteed issue perid? (NOTE: If the answer abve is YES please attach prf f eligibility.) Yes N Yes N 2. D yu have anther Medicare supplement r Medicare select insurance plicy r certificate in frce? (a) If YES, with what cmpany, and what plan d yu have? Name f Cmpany B Name f Cmpany Yes N Yes N Plicy/Certificate Number Plan Plicy/Certificate Number Plan Issue Issue (b) If YES, d yu intend t replace yur current Medicare supplement plicy/certificate with this plicy? (c) If YES, indicate terminatin date. / B (d) If YES, have yu received a cpy f the replacement ntice? If yu have had any ther Medicare plan cverage as referenced belw, nt t include Medicare supplement, please cmplete questins (a-g) belw. If nt, skip t questin #4. 3. If yu had cverage frm any Medicare plan ther than riginal Medicare within the past 63 days (fr example, a Medicare Advantage plan, r a Medicare HMO r PPO), fill in yur start and end dates belw. If yu are still cvered under this plan, leave END blank. START END / START END B (a) If yu are still cvered under the Medicare plan, d yu intend t replace yur current cverage with this new Medicare supplement plicy? (b) If YES, have yu received a cpy f the replacement ntice? Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N (c) Reasn fr terminatin/disenrllment? / B (d) Planned date f terminatin/disenrllment? / B UA P.O. Bx 3608 Omaha, Nebraska

5 (e) Was this yur first time in this type f Medicare plan? (f) Did yu drp a Medicare supplement r Medicare select plicy/certificate t enrll in this Medicare plan? (g) Is yur frmer Medicare supplement r Medicare select plicy/certificate still available? 4. Have yu had cverage under any ther health insurance within the past 63 days? (Fr example, an emplyer, unin, r individual nn-medicare supplement plan) (a) If YES, with what cmpany and what kind f plicy? (List belw) Name f Cmpany Kind f Plicy B Name f Cmpany B Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Kind f Plicy (b) What are yur dates f cverage under the ther plicy? If yu are still cvered under this plan, leave END blank. START END / START END B (c) Reasn fr terminatin/disenrllment? / B (d) Planned date f terminatin/disenrllment? / B 5. Are yu cvered fr medical assistance thrugh the state Medicaid prgram? (NOTE TO APPLICANT: If yu are participating in a Spend-Dwn Prgram and have nt met yur Share f Cst, please answer NO t this questin.) If YES, (a) Will Medicaid pay yur premiums fr this Medicare supplement plicy? (b) D yu receive any benefits frm Medicaid OTHER THAN payment tward yur Medicare Part B premium? 6. Prducers shall list any ther health insurance plicies they have sld t the applicant. (a) List plicies sld which are still in frce. Name f Cmpany B Name f Cmpany Yes N Yes N Yes N Yes N Yes N Yes N Plicy/Certificate Number Descriptin f Benefits Plicy/Certificate Number Descriptin f Benefits Effective f Cverage Effective f Cverage (b) List plicies sld in the past five (5) years which are n lnger in frce. B Name f Cmpany Name f Cmpany Plicy/Certificate Number Descriptin f Benefits Effective f Cverage Plicy/Certificate Number Descriptin f Benefits Effective f Cverage UA P.O. Bx 3608 Omaha, Nebraska

6 If yu are applying during Open Enrllment r a Guaranteed Issue perid, SKIP SECTION 4 and GO TO SECTION PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS. Make sure all questins are answered by each applicant. If either yu r B answer YES t any f the fllwing questins 1-14, that persn is nt eligible fr cverage. T the Best f Yur Knwledge: 1. Are yu currently hspitalized r cnfined t a nursing facility; r, are yu bedridden r cnfined t a wheelchair? 2. Have yu been diagnsed with emphysema, Chrnic Obstructive Pulmnary Disease (COPD) r ther chrnic pulmnary disrders? 3. Have yu been diagnsed with Parkinsn s Disease, Systemic Lupus, Myasthenia Gravis, Multiple r Lateral Sclersis, Osteprsis with fractures, Cirrhsis r kidney disease requiring dialysis? 4. Have yu been diagnsed with Alzheimer s Disease, Senile Dementia, r any ther cgnitive disrder? 5. Have yu been diagnsed with r treated fr Acquired Immune Deficiency Syndrme (AIDS) r AIDS Related Cmplex (ARC)? 6. If yu have diabetes, d yu have any f the fllwing cnditins: diabetic retinpathy, peripheral vascular disease, neurpathy, any heart cnditin (including high bld pressure) r kidney disease? If yu d nt have diabetes, this questin shuld be answered NO. 7. D yu have diabetes that has ever required mre than 50 units f insulin daily? 8. Within the past tw years have yu been treated fr r been advised by a physician t have treatment fr internal cancer, alchlism r drug abuse, mental r nervus disrder requiring psychiatric care r have yu had any amputatin caused by disease? 9. Within the past tw years have yu been treated fr r been advised by a physician t have treatment fr heart attack, heart, crnary r cartid artery disease (nt including high bld pressure), peripheral vascular disease, cngestive heart failure r enlarged heart, strke, transient ischemic attacks (TIA) r heart rhythm disrders? 10. Within the past tw years have yu been treated fr degenerative bne disease, crippling/ disabling r rheumatid arthritis r have yu been advised t have a jint replacement? 11. Have yu been advised by a physician that surgery may be required within the next 12 mnths fr cataracts? 12. Have yu been advised by a physician t have surgery, medical tests, treatment r therapy that has nt been perfrmed? 13. Have yu been hspital cnfined three r mre times in the last tw years? 14. Have yu had an rgan transplant r been advised by a physician t have an rgan transplant? 15. Are yu taking r have yu taken any prescriptin r ver-the-cunter medicatins within the past 12 mnths? If YES, please list the drug and the cnditin in the fllwing table. B Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N (please attach a separate sheet if needed) Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin B (please attach a separate sheet if needed) UA P.O. Bx 3608 Omaha, Nebraska

7 5. HOUSEHOLD DISCOUNT INFORMATION Please Answer BOTH Questins 1 & 2 In This Sectin. Yu may be eligible fr a plicy with a lwer rate based n yur answers t the statements in this sectin. Relatinship t : First Name B 1. I have cntinuusly resided with anther persn fr the last 12 mnths r are married and they are als applying fr this cverage. If YES, please cmplete the infrmatin regarding Relatinship t belw, unless yu AND B are applying fr cverage n THIS applicatin then d nt cmplete the Relatinship t infrmatin. Yes N Yes N 2. I have cntinuusly resided with anther persn fr the last 12 mnths r are married and they have an existing Medicare supplement plicy r certificate with Mutual f Omaha Insurance Cmpany r United Wrld Life Insurance Cmpany r United f Omaha Life Insurance Cmpany. If yu answer YES, t this questin, please cmplete the infrmatin regarding Relatinship t belw. Yes N Last Name Street Address City State ZIP Plicy/Certificate Number UA P.O. Bx 3608 Omaha, Nebraska

8 6. PLEASE READ AND SIGN BELOW IMPORTANT STATEMENTS TO BE READ BY APPLICANT Yu d nt need mre than ne Medicare supplement plicy. If yu purchase this plicy, yu may want t evaluate yur existing health cverage and decide if yu need multiple cverage. Yu may be eligible fr benefits under Medicaid and may nt need a Medicare supplement plicy. If, after purchasing the plicy, yu becme eligible fr Medicaid, the benefits and premiums under yur Medicare supplement plicy can be suspended, if requested, during yur entitlement t benefits under Medicaid fr 24 mnths. Yu must request this suspensin within 90 days f becming eligible fr Medicaid. If yu are n lnger entitled t Medicaid, yur suspended Medicare supplement plicy (r, if that is n lnger available, a substantially equivalent plicy) will be reinstituted if requested within 90 days f lsing Medicaid eligibility. If the Medicare supplement plicy prvided cverage fr utpatient prescriptin drugs and yu enrlled in Medicare Part D while yur plicy was suspended, the reinstituted plicy will nt have utpatient prescriptin drug cverage, but will therwise be substantially equivalent t yur cverage befre the date f the suspensin. If yu are eligible fr, and have enrlled in a Medicare supplement plicy by reasn f disability and yu later becme cvered by an emplyer r unin-based grup health plan, the benefits and premiums under yur Medicare supplement plicy can be suspended, if requested, while yu are cvered under the emplyer r unin-based grup health plan. If yu suspend yur Medicare supplement plicy under these circumstances, and later lse yur emplyer r unin-based grup health plan, yur suspended Medicare supplement plicy (r, if that is n lnger available, a substantially equivalent plicy) will be reinstituted if requested within 90 days f lsing yur emplyer r unin-based grup health plan. If the Medicare supplement plicy prvided cverage fr utpatient prescriptin drugs and yu enrlled in Medicare Part D while yur plicy was suspended, the reinstituted plicy will nt have utpatient prescriptin drug cverage, but will therwise be substantially equivalent t yur cverage befre the date f the suspensin. Cunseling services may be available in yur state t prvide advice cncerning yur purchase f Medicare supplement insurance and cncerning medical assistance thrugh the state Medicaid prgram, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Lw-Incme Medicare Beneficiary (SLMB). I wish t apply fr a Medicare supplement insurance plicy. I represent that my answers and statements n this applicatin are true and cmplete. I understand that, upn acceptance f the cmpleted applicatin, each applicant will receive a separate plicy. I understand that my plicy benefits can start n earlier than my Medicare effective date, my first mnth s premium has been received and/r prcessed and my applicatin has been apprved by. Any persn wh, with intent t defraud knwing that he r she is facilitating a fraud against an insurer, submits an applicatin r files a false r deceptive statement is guilty f insurance fraud. d at, n, City State Mnth Day Year s Signature d at, n, City State Mnth Day Year B s Signature (if applying) Premium Must Accmpany Applicatin I/We certify that during an interview with the prpsed applicant, I/we have truly and accurately recrded in the applicatin the infrmatin supplied by the applicant. (Signature f Licensed Prducer) (Signature f Licensed Prducer) PRODUCER STAMP PRODUCER STAMP UA P.O. Bx 3608 Omaha, Nebraska

9 ADDITIONAL INFORMATION: PART 4 - CON T. HEALTH/MEDICAL QUESTIONS - Questin #15 (please attach a separate sheet if needed) Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin Medicatin Name (cpy ff pharmacy label) Originally Prescribed Frequency and Dsage Diagnsis/Cnditin B (please attach a separate sheet if needed) SECTION FOR ADDITIONAL COMMENTS (please attach a separate sheet if needed) B (please attach a separate sheet if needed) UA P.O. Bx 3608 Omaha, Nebraska

10 Calculate Yur Premium Medicare Supplement Medicare Supplement Plan Befre yu begin: If yu re nt in yur pen enrllment r guarantee issue perid, please g t page 2 t determine yur eligibility fr cverage. Line Steps Example Rate displayed is used fr calculatin purpses nly. s Premium B s Premium #1 Premium Write in yur Med supp plan s premium frm the Outline f Cverage prvided. #2 Husehld Discunt Are yu eligible t receive a husehld discunt? If yes, multiply line #1 by.93. If n, enter the amunt frm line #1. #3 Rate Adjustment If yu re in yur pen enrllment r guarantee issue perid, skip t step #4. On page 2, lcate yur height, then weight. If yur weight is in the Standard clumn, enter the amunt frm line #2. $ $ x.93 = $ In this example, the persn qualifies fr the husehld discunt. $ x 1.20 = $ Persn s weight is in the Class II 20% clumn. If yur weight is in the Class I r II clumn, multiply the amunt n line #2 by: 1.10 if in 10% clumn 1.20 if in 20% clumn #4 Payment Optins Yur mnthly payment is yur last premium entered (line #2 r #3). T determine ther payment schedules, multiply yur mnthly premium by: 3 t pay 4 times a year (quarterly) 6 t pay twice a year (semiannually) 12 t pay nce a year (annually) $ mnthly payment $ quarterly payment $ semiannual payment $1, annual payment Cmplete and return with applicatin Page 1 UC6582_0208

11 Height and Weight Chart Eligibility Find yur height in the left-hand clumn and lk acrss the rw t find yur weight. If yur weight is in the Decline clumn, we re srry, yu re nt eligible fr cverage at this time. Rate Adjustment The clumn heading abve yur weight will indicate yur apprpriate rate adjustment, if any (risk class). Decline Class I (10%) Standard Class I (10%) Class II (20%) Decline Height Weight Weight Weight Weight Weight Weight 4' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < ' 5'' < ' 6'' < ' 7'' < ' 8'' < ' 9'' < ' 10'' < ' 11'' < ' 0'' < ' 1'' < ' 2'' < ' 3'' < ' 4'' < Medicare supplement insurance is underwritten by Mutual f Omaha Plaza Omaha, Nebraska mutualfmaha.cm Plicy frms UM1, UM2, UM3, UM4, UM5, UM6, UM7, UM8, UM9 r state equivalent. Page 2 UC6582_0208

12 Plicy Delivery Mail plicy/plicies t: a) Prducer b) B Prducer Prducer(s) Infrmatin Prducer Name Scial Security N Cmm. % Share Prducer Phne N ( ) Cmmissin Cde Prducer Prducer FAX Number Prducer Name Scial Security N Cmm. % Share Prducer Phne N ( ) Cmmissin Cde Prducer Prducer FAX Number (Nte: Prducers must be under the same cmmissin cde t share r split cmmissins.) Prducer T Cmplete Only If Premium Is T Be Paid With A Business Check/Accunt Initial Payment Is the applicant: Yes N (a) unemplyed?... (b) emplyed, but nt wrking fr the business that is paying the premium?... (c) the business wner r spuse f the business wner?... If (a), (b), r (c) is Yes, the premium can be paid with a business check/accunt. Renewal Payment Is the applicant: Yes N (a) unemplyed?... (b) emplyed, but nt wrking fr the business that is paying the premium?... (c) the business wner r spuse f the business wner?... If (a), (b), r (c) is Yes, the premium can be paid with a business check/accunt.

13 Instructins fr Cmpletin f Authrizatin fr Electrnic Funds Transfer (ACH/BSP) Frm Accunt Hlder Name { Check Number { Jhn De Check #1234 Street Address Twn, City Zip cde : Pay t: Dllars Bank Name & Address Mem : : Signed By: { Bank Ruting/ Transfer Number { Bank Accunt Number { Check Number (if shwn at bttm, may be befre r after the accunt #) D NOT include the check number as part f either the Ruting r Accunt Number. The applicant may select ne f three payment ptins indicated n the back side f this frm. Instructins fr each ptin are listed belw. With each ptin, the frm must be signed and dated. Optin A: Pay all premiums (1st mnth and mnthly renewals) by Electrnic Funds Transfer (EFT). Autmated Clearing Huse (ACH) is used fr initial payment and Bank Service Plan (BSP) is used fr renewal payments. When chsing t pay bth the initial and mnthly renewals by EFT, the applicant must cmplete the frm and submit it with the applicatin. DO NOT submit a signed check fr payment under this ptin. T avid ptential delays in prcessing, submit a vided check and cmplete the accunt infrmatin (ruting/accunt numbers, name f financial institutin) n the frm. Optin B: Pay 1st mnth by paper check and mnthly renewals by BSP When chsing t pay the initial premium via paper check and the mnthly renewals by BSP, the applicant must cmplete the frm and submit it with the applicatin. A signed check fr the initial mnthly premium must be submitted with the applicatin. Optin C: Pay 1st mnth by ACH and pay renewals by direct bill (mnthly direct billing is nt ffered) When chsing t pay the initial premiums by ACH and renewal premiums by direct billing (quarterly, semiannually, r annually), the applicant must cmplete the frm and submit it with the applicatin. DO NOT submit a signed check fr the initial premium payment under this ptin. T avid ptential delays in prcessing, submit a vided check and cmplete the accunt infrmatin (ruting/accunt number, name f financial institutin) n the frm. When chsing t pay initial premiums by ACH, mney will be withdrawn n the date the applicatin is prcessed. This may be different frm the mnthly withdraw date selected fr renewal premiums. Payments cannt be pstpned until a later date. Payment frm a third party, including any fundatin, cannt be accepted. All refunds will be made t the applicant in the event f rejectin, incmplete submissin, verpayment, cancellatin, etc. Please cmplete the Electrnic Funds Transfer frm accurately and in its entirety, making sure that all required infrmatin is crrect and cmplete n yur Electrnic Funds Transfer frm prir t submissin. In additin, please make sure that the premium amunt is filled in n the Electrnic Funds Transfer frm s we can initiate a timely and accurate withdrawal frm yur client s bank accunt. An example f hw t find crrect Ruting and Accunt Numbers n yur clients checks is included at the tp f this frm. D nt include the check number as part f either the Ruting r Accunt Number. The applicant s bank name is nrmally included abve the Mem line n the check. U7535_0409

14 Please refer t instructins n the Frnt f this frm. Authrizatin fr Electrnic Funds Transfer (ACH/BSP) This frm is intended as authrizatin t debit yur accunt. Please cmplete initial and renewal premium payment infrmatin belw. A B Medicare Supplement Premium Payment Optins: YES NO YES NO A. Pay premiums (1st mnth and mnthly renewals) by Electrnic Funds Transfer (ACH is used fr initial payment and BSP is used fr renewal payments.) B. Pay 1st premium by signed paper check and pay mnthly renewals by BSP C. Pay initial premium by ACH and pay renewals by direct bill (mnthly direct billing is nt ffered) If chsing Optins A r C, list amunt f initial premium withdrawal...$ $ If chsing Optins A r B, select a withdrawal date fr mnthly renewal payments (circle ne) st r 15th 1st r 15th Is a Business Accunt being used t pay premiums? If yes, is the applicant: (a) Unemplyed (b) Emplyed, but nt wrking fr the business that is paying the premium (c) The business wner r spuse f the business wner... If (A), (B), r (C) are Yes, premiums CAN be paid with a business accunt. A B Cmplete the infrmatin belw. T avid ptential delays in prcessing, submit a cpy f a vided check. Accunt Type (check ne): Checking Savings Accunt Type (check ne): Checking Savings Name f Financial Institutin Ruting Number (first 9 digits n lwer left side f check) Accunt Number (D NOT use Debit r Credit Card accunt numbers) Name as Shwn n Accunt Name f Financial Institutin Ruting Number (first 9 digits n the lwer left side f check) Accunt Number (D NOT use Debit r Credit Card accunt numbers) Name as Shwn n Accunt IMPORTANT: Withdrawal date f the initial premium payment will ccur when the applicatin is prcessed and may be different than the mnthly withdrawal date selected abve. I authrize ( United f Omaha ) t withdraw funds frm my accunt fr my initial and/r mnthly renewal premiums and understand that the amunts may differ. I als authrize United f Omaha t cllect any premium(s) due by bank draft withdrawal. Premium shrtages may result frm a variety f causes, including underwriting adjustments. I authrize yu, my financial institutin, t pay frm my accunt any checks, drafts r preauthrized electrnic fund transfers frm my accunt t United f Omaha. Yur rights with each charge will be the same as if persnally paid by me. The authrizatin will be effective until I give yu at least three business days ntice t cancel it. If ntice is given verbally, yu may require written cnfirmatin frm me within 14 days after my verbal ntice. Authrized Signature as Shwn n Accunt Authrized Signature as Shwn n Accunt U7535_0409

15 Cnditinal Receipt Check r Mney Order Applicatin All premiums must be made payable t the. D nt make check r mney rder payable t the agent r leave the payee blank. B Received f Received f this day f this day f,, an applicatin fr Frm Plicy an applicatin fr Frm Plicy and/r Riders and and/r Riders and Check r Mney Order fr Dllars. Check r Mney Order fr Dllars. Shuld the Cmpany decline t issue the insurance applied fr, I hereby agree t return the abve sum t the applicant. Agent Shuld the Cmpany decline t issue the insurance applied fr, I hereby agree t return the abve sum t the applicant. Agent NOTICE TO APPLICANT: Eligibility fr the health and accident insurance applied fr is cnditinal upn all f the fllwing: (a) payment f the full, initial premium; (b) written applicatin; (c) satisfying the Cmpany s underwriting standards. If yu are nt eligible, n insurance r temprary r interim insurance f any kind will be effective. Cmplete Receipt in full and leave with applicant at time f applicatin. - Ntice f Infrmatin Practices In the curse f prperly underwriting and administering yur insurance cverage, we will rely heavily n infrmatin prvided by yu. We may als cllect infrmatin frm thers, such as medical prfessinals wh have treated yu, hspitals, ther insurance cmpanies, and cnsumer reprting agencies. In certain circumstances, and in cmpliance with applicable law, we r ur reinsurers may als release yur persnal r privileged infrmatin in ur/their files, t third parties withut yur authrizatin. Upn request, yu have the right t be tld abut and t see a cpy f items f persnal infrmatin abut yu which appear in ur files, including infrmatin cntained in investigative cnsumer reprts. Yu als have the right t seek crrectin f persnal infrmatin yu believe t be inaccurate. In cmpliance with applicable law, we r ur reinsurers may als release infrmatin in ur/their files, including infrmatin in an applicatin, t ther insurance cmpanies t which yu apply fr life r health insurance r t which a claim is submitted. S that there will be n questin that the insurance benefits will be payable at the time a claim is made, we urge yu t review yur applicatin carefully t be sure the answers are crrect and cmplete. 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 Give this ntice t the applicant.

16 Authrizatin T Disclse Persnal Infrmatin T Meanings f Terms Medical Persns and Entities means: all physicians, medical r dental practitiners, hspitals, clinics, pharmacies, pharmacy benefit managers, ther medical care facilities, health maintenance rganizatins and all ther prviders f medical r dental services. Persnal Infrmatin means: all health infrmatin, such as medical histry, mental and physical cnditin, prescriptin drug recrds, drug and alchl use and ther infrmatin such as finances, ccupatin, general reputatin and insurance claims infrmatin abut me. Persnal Infrmatin des nt include Psychtherapy Ntes. Psychtherapy Ntes means: ntes recrded by a health care prvider wh is a mental health prfessinal dcumenting r analyzing the cntents f cnversatin during a cunseling sessin, which ntes are separated frm the rest f the persn s medical recrd. Certain infrmatin, such as that relating t prescriptins, diagnsis and functinal status, is nt included in the term Psychtherapy Ntes. Specified Cmpanies means: The grup f cmpanies which presently includes Mutual f Omaha Insurance Cmpany, United f Omaha Life Insurance Cmpany, United Wrld Life Insurance Cmpany, Cmpanin Life Insurance Cmpany, additinal cmpanies which may becme part f this grup f cmpanies and their successrs. Other persns and entities which act n behalf f thse cmpanies t prvide services t them. Authrizatin t Disclse I authrize the Medical Persns and Entities, the Specified Cmpanies, emplyers, cnsumer reprting agencies and ther insurance cmpanies t disclse Persnal Infrmatin abut me t. Purpses The Persnal Infrmatin will be used t determine my eligibility fr insurance and t reslve r cntest any issues f incmplete, incrrect r misrepresented infrmatin n my applicatin which may arise during the prcessing f my applicatin r in cnnectin with claims fr insurance benefits. Ptential fr Redisclsure If the persn r entity t whm Persnal Infrmatin is disclsed is nt a health care prvider r health plan subject t federal privacy regulatins, the Persnal Infrmatin may then be subject t further disclsure by that persn r entity withut the prtectins f the federal privacy regulatins. Failure t Sign I understand that I may refuse t sign this authrizatin. I realize that if I refuse t sign, the insurance fr which I am applying will nt be issued. Expiratin and Revcatin Unless revked earlier, this authrizatin will remain in effect fr 24 mnths frm the date I sign it. I understand that I may revke this authrizatin at any time, by written ntice t: ATTN: Individual Underwriting Mutual f Omaha Plaza Omaha, NE I realize that my right t revke this authrizatin is limited t the extent that has taken actin in reliance n the authrizatin r the law allws t cntest the issuance f the plicy r a claim under the plicy. Cpy I understand that I will receive a cpy f the signed authrizatin. A cpy f this authrizatin is as effective as the riginal. Names and Signatures Name(s) used fr medical recrds (if different than the name(s) belw): Printed Name f Prpsed Signature f Prpsed B Printed Name f Prpsed Signature f Prpsed U7566_0709 THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS

17 Ntice t Regarding Replacement f Medicare Supplement Insurance r Medicare Advantage Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing Medicare supplement r Medicare Advantage insurance and replace it with a plicy t be issued by. Yur new plicy will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy. Yu shuld review this new cverage carefully. Cmpare it with all accident and sickness cverage yu nw have. If, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin, yu shuld terminate yur present Medicare supplement r Medicare Advantage cverage. Yu shuld evaluate the need fr ther accident and sickness cverage yu have that may duplicate this plicy. Statement t by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. T the best f my knwledge, this Medicare supplement plicy will nt duplicate yur existing Medicare supplement r, if applicable, Medicare Advantage cverage because yu intend t terminate yur existing Medicare supplement cverage r leave yur Medicare Advantage plan. The replacement plicy is being purchased fr the fllwing reasn(s) (check ne): B Additinal benefits Additinal benefits N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan Please explain reasn fr disenrllment Other (please specify) N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan Please explain reasn fr disenrllment Other (please specify) If, yu still wish t terminate yur present plicy r certificate and replace it with new cverage, be certain t truthfully and cmpletely answer all questins n the applicatin cncerning yur medical and health histry. Failure t include all material medical infrmatin n an applicatin may prvide a basis fr the Cmpany t deny any future claims and t refund yur premium as thugh yur plicy had never been in frce. After the applicatin has been cmpleted and befre yu sign it, review it carefully t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy r certificate until yu have received yur new plicy and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative*, Mutual f Omaha Plaza, Omaha, NE Signature B Signature *Signature nt required fr direct respnse sales. U Hme Office Cpy 2 - Cpy

18 Ntice t Regarding Replacement f Medicare Supplement Insurance r Medicare Advantage Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing Medicare supplement r Medicare Advantage insurance and replace it with a plicy t be issued by. Yur new plicy will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy. Yu shuld review this new cverage carefully. Cmpare it with all accident and sickness cverage yu nw have. If, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin, yu shuld terminate yur present Medicare supplement r Medicare Advantage cverage. Yu shuld evaluate the need fr ther accident and sickness cverage yu have that may duplicate this plicy. Statement t by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. T the best f my knwledge, this Medicare supplement plicy will nt duplicate yur existing Medicare supplement r, if applicable, Medicare Advantage cverage because yu intend t terminate yur existing Medicare supplement cverage r leave yur Medicare Advantage plan. The replacement plicy is being purchased fr the fllwing reasn(s) (check ne): B Additinal benefits Additinal benefits N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan Please explain reasn fr disenrllment Other (please specify) N change in benefits, but lwer premiums Fewer benefits and lwer premiums My plan has utpatient prescriptin drug cverage and I am enrlling in Part D Disenrllment frm a Medicare Advantage Plan Please explain reasn fr disenrllment Other (please specify) If, yu still wish t terminate yur present plicy r certificate and replace it with new cverage, be certain t truthfully and cmpletely answer all questins n the applicatin cncerning yur medical and health histry. Failure t include all material medical infrmatin n an applicatin may prvide a basis fr the Cmpany t deny any future claims and t refund yur premium as thugh yur plicy had never been in frce. After the applicatin has been cmpleted and befre yu sign it, review it carefully t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy r certificate until yu have received yur new plicy and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative*, Mutual f Omaha Plaza, Omaha, NE Signature B Signature *Signature nt required fr direct respnse sales. U Hme Office Cpy 2 - Cpy

19 Medicare Select Plicy Disclsure Agreement I acknwledge receipt f the fllwing infrmatin: 1. Outline f Cverage 2. Descriptin f the restricted netwrk prvisins including: (a) netwrk prviders; (b) payments fr cinsurance and deductibles when prviders ther than netwrk prviders are utilized; (c) cverage fr emergency and urgently needed care and ther ut f service area cverage; (d) limitatins n referrals t restricted netwrk prviders; (e) descriptin f my rights t purchase a Medicare supplement plicy f equal r lesser benefits ffered in my state by United f Omaha; (f) s Quality Assurance Prgram; and (g) s Grievance Prcedures. I als understand the fllwing: United f Omaha des nt recmmend the purchase f a Medicare select plicy if I live mre than 30 miles frm a netwrk hspital; unless the netwrk hspital is the clsest hspital which ffers this level f service. I have received full and fair disclsure f the infrmatin described abve. Signature f the Prpsed Signature f the Prpsed B U7568