Learn the Truth. Know the Risk. Protect Your Income. Short-Term Disability Prepared for: Presented by: SYLVIA GIVENS-DUNNING Eric Fribush none 800-427-9141 Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Eric Fribush Date: 12/10/2015 Version: 1.73 Policy Form: D82 Page: 1 of 7
Premium Premium Includes Monthly Premium Monthly Disability Benefit $2,400 (Includes Base Disability Benefit only) Base Disability Benefit $2,400 per month $ 93.88 Waiver of Premium No Cost Total Premium After Savings if Applied Available Premium Savings Monthly BSP (Bank Service Plan) Premium $93.88 Quarterly Premium $278.94 Semi-Annual Premium $552.52 Annual Premium $1,072.86 (*Premium savings does not apply to this rider) Note: There is an additional cost for premium payments made more frequently than once a year. You ve taken the first step toward protecting your family s income. Now share the news with your co-workers and save an additional 15% off your current premiums by qualifying for the Common Employer discount. Ask your Producer for details. Policy Summary The total potential maximum benefit assuming payment of the full monthly benefit for the entire benefit period is $7,200. Short-Term Disability - This policy pays the insured a monthly cash benefit of $2,400 for up to 3 months as long as they are totally disabled and unable to work because of a covered accident or sickness. Benefits begin after 14 days of a period of disability. This policy is guaranteed renewable to the insured's age 67. After the insured has attained the age of 67, the policy may continue to renew until the first policy renewal following the insured's 75th birthday providing the insured is working full-time. This is a premium quote for a Short-Term Disability policy, not an offer, and is subject to regular underwriting. Please refer to the Summary/Outline of coverage for more details, including information regarding exceptions, limitations, and reductions of your coverage. Presented by: Mutual of Omaha - Eric Fribush License Number: none Date: 12/10/2015 Version: 1.73 Policy Form: D82 Page: 2 of 7
Age: 58 / Female / Non-Tobacco User / ST Benefit Period: 3 Months PROVISIONS Total Disability Presumptive Total Disability Partial Disability During the 14 day elimination period and during the first 24 months following the elimination period, total disability due to sickness or injury means that the insured: 1) is unable to perform with reasonable continuity the substantial and material acts necessary to perform your usual occupation in the usual and customary way, and; you choose not to work at any occupation; and 2) is under the regular medical care of a physician. The insured will be presumed totally disabled and the normal total disability requirements will be waived if they incur any of the following uncorrectable losses due to sickness or injury: Speech Hearing in both ears Sight in both eyes The use of both hands, both feet or one hand and one foot Benefits are payable at 100% of the Total Disability Monthly Benefit and the elimination period is waived. The Insured's ability to work will not affect the benefits and proof of further medical treatment will not be required. If you are partially disabled because of a sickness or injury, we will pay 50% of the total disability monthly benefit. Partial disability benefits begin after the elimination period has been satisfied. Benefits are payable while you remain partially disabled for the lesser of six months or the balance of the benefit period. Version: 1.73 Policy Form: D82 Page: 3 of 7
Proposed Insured: SYLVIA GIVENS-DUNNING State of Issue: CA Waiver of Premium Exclusions and Limitations This proposal is not a contract. Please refer to your Outline of Coverage or contract for statespecific exclusions and limitations. Waiver of Premium pays the premium when the insured meets the definition of total disability, partial disability, or presumptive total disability. Premium is waived after 90 days of disability until the end of the benefit period. There is no additional cost for this benefit. We will not pay benefits for: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) loss that begins while this policy is not in force; loss resulting from an act of declared or undeclared war; loss sustained while serving in the armed forces (upon notice to us of entry into the armed forces, the unearned portion of the premium will be refunded); loss caused by intentionally self-inflicted injury; loss resulting from commission or attempted commission of a felony; loss caused by suicide or attempted suicide, while sane or insane; loss resulting from your being legally intoxicated or under the influence of an illegal substance or a narcotic (except for narcotics given on the advice of and taken as prescribed by a Physician); loss for which benefits are provided under any state or federal worker s compensation, employer s liability or occupational disease law; loss resulting from Substance Abuse; or loss resulting from Mental or Nervous Disorders. Pregnancy: Benefits are not payable for loss due to Normal childbirth, Normal Pregnancy or voluntarily induced abortion. We will pay benefits for Complications of Pregnancy on the same basis as any other Sickness. Exclusions and Limitations are different in CA, CT, NV, NY, PA, SD, VT and WA. Please ask your producer for an Outline. Version: 1.73 Policy Form: D82 Page: 4 of 7
Long-Term Disability D81 Short-Term Disability D82 Accident Only Disability D83 Total Monthly Benefit Amount MEDICAL UNDERWRITING GUIDELINES MEDICAL UNDERWRITING GUIDELINES Accident Only Disability Short-Term Disability 2-Year and 5- Year Benefit Period Long-Term Plan 10-Year and To Age 67 Benefit Period Interview $300-$3,000 Simplified Simplified Underwriting 1 Interview $3,100-$5,000 Underwriting 1 Interview Interview, Physical Data, Blood and Urine $5,100-$8,000 Interview, Interview, Long Physical Data, Form Paramed, Blood and Urine Blood and Urine Business Operating Expense Simplified Underwriting 1 Interview Interview, Physical Data, Blood and Urine Interview, Long Form Paramed, Blood and Urine, EKG 2 $8,100 and Above Interview, Long Form Paramed, Blood and Urine, EKG 2 Interview, Long Form Paramed, Blood and Urine, EKG 2 1 Underwriting decisions within 48 hours of initial underwriting review provided the following conditions are met: Applicant is in occupation class 6A, 5A, 4A, 3A, or 2A For Accident Only Disability coverage: Applicant is age 55 or younger and medically standard For Short-Term and Long-Term Disability coverage: Applicant is nontobacco, age 45 or younger, and medically standard No adverse information from the Medical Information Bureau All application questions have been clearly and completely answered and required forms and financial documents have been submitted with the application 2 Age 45 and over only Version: 1.73 Policy Form: D82 Page: 5 of 7
Age: 58 / Female / Non-Tobacco User / ST Benefit Period: 3 Months Income Documentation Financial Underwriting Guidelines The last two years taxes are required for individuals applying for the self-employed preferential rates. If you qualify for the selfemployed discount, you will also be eligible for the automatic income increase of up to 20%, which can provide up to an additional $1000 in monthly benefit. Individuals who have been self-employed less than 12 months but are engaged in the same occupation or line of work as previously employed (W-2) may be eligible for up to 50% of prior two years W-2 earnings. Newly Self-Employed eligibility requirements are listed in the underwriting Guidelines Note: Net income (income less business expenses prior to taxes) is used for self-employed individuals; Gross income is used for salaried individuals. Version: 1.73 Policy Form: D82 Page: 6 of 7
Alternate Premiums for Short-Term Disability Elimination Periods Benefit Periods 0/7 days 0/14 days 7/7 days 14 days 30 days 60 days 90 days 3 months Base Benefit $133.19 $112.95 $120.17 $93.88 $60.20 $48.59 $31.20 TOTAL* $133.19 $112.95 $120.17 $93.88 $60.20 $48.59 $31.20 6 months Base Benefit $196.50 $167.81 $180.37 $143.62 $98.65 $82.28 $57.69 TOTAL* $196.50 $167.81 $180.37 $143.62 $98.65 $82.28 $57.69 12 months Base Benefit $244.19 $210.55 $227.03 $184.47 $138.97 $117.14 $84.41 TOTAL* $244.19 $210.55 $227.03 $184.47 $138.97 $117.14 $84.41 24 months Base Benefit $378.40 $327.57 $351.48 $287.24 $217.43 $176.58 $115.26 TOTAL* $378.40 $327.57 $351.48 $287.24 $217.43 $176.58 $115.26 * TOTAL (includes policy fee and premium savings, if any) Version: 1.73 Policy Form: D82 Page: 7 of 7