Exhibit 1.A(10) Form of Application for the United of Omaha Life Insurance
Company ULTRA LIFE Flexible Premium Variable Life Insurance Policy
APPLICATION TO:
UNITED OF OMAHA LIFE INSURANCE COMPANY
[ ] ATTN: Life Agency: Mutual of Omaha Plaza, Omaha, NE 68175
[ ] ATTN: Life Brokerage: P.O. Box 2476, Omaha, NE 68103-2476
FOR
[ ] LIFE INSURANCE [ ] FLEXIBLE PREMIUM VARIABLE
[ ] ADULT LIFE [ ] UNIVERSAL LIFE INSURANCE
[ ] JUVENILE LIFE [ ] ADDITIONAL INSURED RIDER (AIR)
[ ] SPECIFIED AMOUNT INCREASE
TO THE AGENT/BROKER:
0 Tear off the Notice of Exchange of Information and the Summary of Rights
Under the Fair Credit Reporting Act and give it to the Applicant.
0 Have Authorization To Release Information on reverse side of this page
signed and dated.
0 Assure that all applicable questions in Part I and Part II are answered in
clear printed fashion.
0 Complete Nonmedical Supplement in all cases.
0 Be sure the application is signed by the Proposed Insured(s) and the
Applicant if other than Proposed Insured(s).
0 Any changes should be initialed by the Proposed Insured(s) and, if
applicable, the Applicant.
0 Use age last birthday.
0 Always provide the attached Temporary Life Insurance Agreement and Receipt
when you accept a premium.
PREMIUM ACCEPTANCE GUIDELINES:
Premium should only be accepted if:
(a) Questions 1, 2 and 3 on the Temporary Life Insurance Agreement and
Receipt form are answered "No."
(b) The Temporary Life Insurance Agreement and Receipt form is signed,
dated and witnessed by all parties indicated on the form on the day the
application is taken.
(c) A full modal premium is collected at the time of application unless the
Bank Service Plan (BSP) is used, in which case two BSP premiums should be
collected.
(d) The total amount of insurance applied for does not exceed $250,000 if
term insurance is requested or $1,500,000 if permanent (Whole Life, Universal
Life or Variable Universal Life) insurance is requested.
United of Omaha Life Insurance Company
Instructions to Agent/Broker: Give this Notice to the
Applicant before filling out the application.
NOTICE OF EXCHANGE OF INFORMATION
MEDICAL INFORMATION BUREAU, INC. (MIB) The information regarding your
insurability will be treated as confidential.
However, the Company or its reinsurers may make a brief report to
the Medical Information Bureau, a nonprofit membership organization of life
insurance companies which operates an information exchange for its members. If
you apply for life or health insurance to another company which is also a member
of the Bureau or if a claim for benefits is submitted to such a company, the
Bureau will, upon request, supply the information in its file to that company.
Florida residents: However, no information obtained from the Medical Information
Bureau pertaining to Human Immunodeficiency Virus (HIV) or Acquired Immune
Deficiency Syndrome (AIDS) will affect the issuance or the underwriting of the
policy, except upon written consent to be medically tested for HIV or AIDS and
the results of such testing proved positive.
Upon receipt of a request from you, the Medical Information Bureau will arrange
disclosure of any information it may have in your file. If you question the
accuracy of the information in the Bureau's file, you may contact the Bureau and
seek a correction in accordance with the procedures set forth in the federal
Fair Credit Reporting Act. The address of the Bureau's information office is
P.O. Box 105, Essex Station, Boston, MA 02112, phone (617) 426-3660.
The Company or its reinsurers may also release information in its file,
including information given in your application, to other insurance companies to
which you apply for life or health insurance or to which a claim is submitted.
(See reverse side for other important notices.)
AUTHORIZATION TO RELEASE INFORMATION (FOR ALL STATES, EXCEPT ARIZONA, HAWAII AND
MICHIGAN)
To
United of Omaha Life Insurance Company
To all physicians, medical or dental practitioners, hospitals, clinics, other
medical care facilities or other providers of medical or dental care services,
insurers, employers and consumer reporting agencies:
I authorize you to release all medical and nonmedical information about me
(the undersigned) or my children to United of Omaha Life Insurance Company, its
reinsurers and any consumer reporting agency acting for them. This authorization
includes information about medical history, mental and physical condition, drug
and alcohol use, and other personal information such as finances, occupation and
general reputation.
To the Medical Information Bureau, Inc. (MIB):
I authorize you to release all medical and nonmedical information about me
(the undersigned) to United of Omaha Life Insurance Company and its reinsurers.
This authorization includes information about medical history, mental and
physical condition, drug and alcohol use, and other personal information.
Information received will be used to determine insurability. This authorization
is valid for 30 months from the date below. A photocopy of this authorization is
as valid as the original. I have received the Notice of Information Gathering
Practices, the Notice of Exchange of Information, including MIB, and Fair Credit
Reporting Act Notice. I, or my authorized representative, will receive a copy of
this authorization and any investigative consumer report upon request.
If an investigative consumer report is prepared, I may request to be
interviewed. (Check if an interview is desired.)
Name used for medical records_____________________________________
__________________________________________________________________________
Date Signature of Proposed Insured(s) (Age 15 or older)
__________________________________________________________________________
Date Signature of Proposed Insured(s) (Age 15 or older)
__________________________________________________________________________
Date Signature of Parent or Guardian
(if Proposed Insured is under Age 15)
UNITED OF OMAHA LIFE INSURANCE COMPANY
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
Mutual of Omaha Insurance Company and/or United of Omaha Life Insurance Company,
or its/their duly authorized representative(s), may request and obtain an
investigative consumer report for the purpose of serving as a factor in the
underwriting of your insurance application.
An investigative consumer report means any written, oral or other communication
of any information by a consumer reporting agency bearing on your character,
general reputation, personal characteristics or mode of living obtained through
personal interviews with your neighbors, friends, acquaintances, associates, or
those who may have knowledge concerning such items of information.
Upon written request we will provide you with additional disclosures relating to
the nature and scope of the investigative consumer report. Following this
Disclosure Statement is a written Summary of Your Rights Under Section 606 (a)
of the Fair Credit Reporting Act, as amended.
If you request the additional disclosures and/or summary of rights from either
United of Omaha Life Insurance Company or Mutual of Omaha Insurance Company,
please send your request to the following address: Attention: Individual
Underwriting Department, Mutual of Omaha Plaza, Omaha, Nebraska 68175
NOTICE OF INFORMATION PRACTICES
In the course of properly underwriting and administering your insurance
coverage, United of Omaha Life Insurance Company will rely heavily on
information provided by you. The Company may also collect information from
others, such as medical professionals who have treated you.
In certain circumstances, and in compliance with applicable law, our Company may
disclose personal or privileged information to third parties without your
specific authorization.
You have the right to be told about and to see a copy, if you wish, of items of
personal information about you which appear in our files, including information
contained in investigative consumer reports. You also have the right to seek
correction of personal information you believe to be inaccurate.
THE ABOVE IS A GENERAL DESCRIPTION OF THE COMPANY'S AND YOUR AGENT'S/BROKER'S
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, UNDERWRITING DEPARTMENT, MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175.
RECEIPT (Agent/Broker -- See Premium Acceptance Guidelines -- Page 1)
ALL CHECKS MUST BE MADE PAYABLE TO UNITED OF OMAHA. UNITED WILL NOT
ACCEPT CASH PREMIUMS. DO NOT MAKE CHECKS PAYABLE TO THE AGENT/BROKER OR LEAVE
THE PAYEE BLANK.
TEMPORARY LIFE INSURANCE AGREEMENT AND RECEIPT ("Agreement")
United of Omaha Life Insurance Company ("United"), Mutual of Omaha Plaza, Omaha,
NE 68175
The following questions must be answered either "Yes" or "No." YES NO
1. Within the past 90 days, has any Proposed Insured been admitted to a hospital
or other medical facility, been advised to be admitted, had surgery performed or
recommended, or been advised to have a diagnostic test other than an HIV test?
2. Within the past three years, has any Proposed Insured been treated for
heart trouble, stroke, cancer, drug or alcohol use, or had such treatment
recommended by a physician or other licensed medical professional?
3. Has any Proposed Insured ever been diagnosed as having Acquired Immune
Deficiency Syndrome or AIDS Related Complex (ARC) caused by the HIV infection,
or been treated for or had treatment recommended for AIDS or ARC by a physician
or other licensed medical professional? (Wisconsin Residents: any AIDS test
result received at an anonymous counseling and testing site need not be
disclosed.)
4. Is any Proposed Insured under 15 days old or over 70 years of age?
If any of the above questions are answered "Yes" or not answered, no
Agent/Broker of United is authorized to accept money with the application and no
coverage will take effect under this Agreement. In consideration of the
application and payment of $ _______________ by the Applicant, receipt of which
is hereby acknowledged, United agrees to provide temporary life insurance for
the Proposed Insured(s) effective on the date of the application, for a limited
period of time, subject to the following conditions and limitations.
A. If the answer to any of the above questions is "No" and the answer is
incorrect or misleading, or if any of the answers to the questions on the
application are incorrect or misleading, then this Agreement is void and never
went into effect.
B. Temporary life insurance under this Agreement will automatically terminate on
the earliest of the following dates:
(1) 90 days from the date of this Agreement, except in Connecticut; or
(2) The date that insurance takes effect under the policy applied for; or
(3) The date of the letter offering to the Applicant a policy, other than
applied for; or
(4) The date a policy, other than as applied for, is offered by an Agent/Broker
to the Applicant; or
(5) The date the premium refund is mailed; or
(6) The date any check or draft submitted as payment is not honored by the bank
on which it is drawn; or
(7) The date United mails notice of termination of coverage.
C. If the policy applied for is either (a) pursuant to a conversion privilege in
(an) existing United Life policy(ies), or (b) to replace (an) existing United
life policy(ies) with another United life policy, then in the event of the death
of the Proposed Insured before the termination of this Agreement, United will
pay only the greater of:
(1) the benefits due under the terms of the existing policy(ies) which is/are
being converted or replaced, or
(2) the benefits due under the terms of the policy for which application is
being made (subject to the further limitation on the maximum amount of benefits
payable under this Agreement which is set forth below); and Applicant
acknowledges and agrees that benefits shall not be payable under both.
D. The temporary life insurance provided by this Agreement is subject to the
provisions of the policy form applied for; however, no benefits will be paid
for:
(1)disability; or
(2) death from suicide while sane or insane (in Missouri, only if suicide was
intended at the time of this application and we can prove it was intended); or
(3) the same loss under both this Agreement and any life policy issued from the
application.
This Agreement does not limit United in applying its underwriting standards to
the application nor does this Agreement limit or waive any rights under any life
insurance policy issued. If the application is rejected by United, the amount
paid with the application will be refunded to the Applicant regardless of
whether a claim has been filed or benefits have been paid under this Agreement.
No change may be made to the terms and conditions of this Agreement by anyone,
including the Agent/Broker.
If any Proposed Insured dies prior to the termination of this Agreement, United
will pay the beneficiary the face amount applied for (unless otherwise required
by C above), not to exceed $250,000 if the policy requested is term insurance,
or not to exceed $1,500,000 if the policy requested is permanent (Whole Life,
Universal Life or Variable Life) insurance.
I have read and received a copy of this Agreement and understand and agree to
all of its terms. I verify the above answers are true to the best of my
knowledge and belief.
Signed this __________ day of ______________ , _____ , at City State ZIP Code
_____________________________________ ___________________________________
Signature of Proposed Insured Printed Name of Proposed Insured
_____________________________________ ___________________________________
Signature of Applicant
(if other than Proposed Insured) Printed Name of Applicant
_____________________________________ ___________________________________
Signature of Spouse
(if a Proposed Insured) Printed Name of Spouse
_____________________________________ ___________________________________
Signature of Agent(s)/Broker(s) Printed Name of Agent(s)/Broker(s)
SUBMIT THIS COPY TO THE COMPANY RECEIPT
(Agent/Broker --- See Premium Acceptance Guidelines -- Page 1)
ALL CHECKS MUST BE MADE PAYABLE TO UNITED OF OMAHA. UNITED WILL NOT ACCEPT CASH
PREMIUMS. DO NOT MAKE CHECKS PAYABLE TO THE AGENT/BROKER OR LEAVE THE PAYEE
BLANK.
TEMPORARY LIFE INSURANCE AGREEMENT AND RECEIPT ("Agreement")
United of Omaha Life Insurance Company ("United"), Mutual of Omaha Plaza, Omaha,
NE 68175
The following questions must be answered either "Yes" or "No." YES NO
1. Within the past 90 days, has any Proposed Insured been admitted to a hospital
or other medical facility, been advised to be admitted, had surgery performed or
recommended, or been advised to have a diagnostic test other than an HIV test?
2. Within the past three years, has any Proposed Insured been treated for heart
trouble, stroke, cancer, drug or alcohol use, or had such treatment recommended
by a physician or other licensed medical professional?
3. Has any Proposed Insured ever been diagnosed as having Acquired Immune
Deficiency Syndrome or AIDS Related Complex (ARC) caused by the HIV infection,
or been treated for or had treatment recommended for AIDS or ARC by a physician
or other licensed medical professional? (Wisconsin Residents: any AIDS test
result received at an anonymous counseling and testing site need not be
disclosed.)
4. Is any Proposed Insured under 15 days old or over 70 years of age?
If any of the above questions are answered "Yes" or not answered, no
Agent/Broker of United is authorized to accept money with the application and no
coverage will take effect under this Agreement.
In consideration of the application and payment of $ _______________ by the
Applicant, receipt of which is hereby acknowledged, United agrees to provide
temporary life insurance for the Proposed Insured(s) effective on the date of
the application, for a limited period of time, subject to the following
conditions and limitations.
A. If the answer to any of the above questions is "No" and the answer is
incorrect or misleading, or if any of the answers to the questions on the
application are incorrect or misleading, then this Agreement is void and never
went into effect.
B. Temporary life insurance under this Agreement will automatically terminate on
the earliest of the following dates:
(1) 90 days from the date of this Agreement, except in Connecticut; or
(2) The date that insurance takes effect under the policy applied for; or
(3) The date of the letter offering to the Applicant a policy, other than
applied for; or
(4) The date a policy, other than as applied for, is offered by an Agent/Broker
to the Applicant; or
(5) The date the premium refund is mailed; or
(6) The date any check or draft submitted as payment is not honored by the bank
on which it is drawn; or
(7) The date United mails notice of termination of coverage.
C. If the policy applied for is either (a) pursuant to a conversion privilege in
(an) existing United Life policy(ies), or (b) to replace (an) existing United
life policy(ies) with another United life policy, then in the event of the death
of the Proposed Insured before the termination of this Agreement, United will
pay only the greater of:
(1) the benefits due under the terms of the existing policy(ies) which is/are
being converted or replaced, or
(2) the benefits due under the terms of the policy for which application is
being made (subject to the further limitation on the maximum amount of benefits
payable under this Agreement which is set forth below); and Applicant
acknowledges and agrees that benefits shall not be payable under both.
D. The temporary life insurance provided by this Agreement is subject to the
provisions of the policy form applied for; however, no benefits will be paid
for:
(1) disability; or
(2) death from suicide while sane or insane (in Missouri, only if suicide was
intended at the time of this application and we can prove it was intended); or
(3) the same loss under both this Agreement and any life policy issued from the
application.
This Agreement does not limit United in applying its underwriting standards to
the application nor does this Agreement limit or waive any rights under any life
insurance policy issued. If the application is rejected by United, the amount
paid with the application will be refunded to the Applicant regardless of
whether a claim has been filed or benefits have been paid under this Agreement.
No change may be made to the terms and conditions of this Agreement by anyone,
including the Agent/Broker.
If any Proposed Insured dies prior to the termination of this Agreement, United
will pay the beneficiary the face amount applied for (unless otherwise required
by C above), not to exceed $250,000 if the policy requested is term insurance,
or not to exceed $1,500,000 if the policy requested is permanent (Whole Life,
Universal Life or Variable Life) insurance.
I have read and received a copy of this Agreement and understand and agree to
all of its terms. I verify the above answers are true to the best of my
knowledge and belief.
Signed this __________ day of ______________ , _____ , at City State ZIP Code
_____________________________________ ___________________________________
Signature of Proposed Insured Printed Name of Proposed Insured
_____________________________________ ___________________________________
Signature of Applicant
(if other than Proposed Insured) Printed Name of Applicant
_____________________________________ ___________________________________
Signature of Spouse
(if a Proposed Insured) Printed Name of Spouse
_____________________________________ ___________________________________
Signature of Agent(s)/Broker(s) Printed Name of Agent(s)/Broker(s)
GIVE THIS COPY TO THE APPLICANT
A. GENERAL QUESTIONS:
1. Proposed Insured's Name: Former Name (if applicable):
2. Home Phone Number: ( ) Best Time to Call: a.m. p.m.
3. Legal Residence Address:
Street No., Apt. No. City, State Zip
4. Mailing Address:
Street No., Apt. No. City, State Zip
5. Mail Premium Notices to: [ ] Residence [ ] Owner [ ] Business
Address:
Street No., Apt. No. City, State Zip
6. Sex: [ ] M [ ] F Age: Birth Date:____/____/____
Birthplace (state):
7. Social Security Number: Driver's License Number:
State of Issue:
8. Are you a U.S. citizen? [ ] Yes [ ] No If "No," date of arrival
in U.S._____________________________________
Do you have an alien registration receipt "Permanent Visa"? [ ] Yes
[ ] No If "Yes," Permanent Visa No.:________
9. Occupation:____________________ Duties:_____________________________
Businessowner? [ ] Yes [ ] No Retired Military? [ ] Yes [ ] No
Active Duty? [ ] Yes [ ] No
If "Yes," are you on flying status or receiving hazardous duty pay?
[ ] Yes [ ] No
If "Yes," explain type of duty or type of aircraft:
10. Name of your firm or employer:
11. Business Phone Number: ( ) Best Time to Call: a.m. p.m.
12. Local Business Address:
Street No., Apt. No. City, State Zip
13. Do you use tobacco in any form? [ ] Yes. What form?____________________
No. per day:__________
[ ] No. [ ] Never Used. [ ] Stopped on _____/_____/_____
14. Applicant/Owner Name (if different from Proposed Insured or if Proposed
Insured is under Age 15):
Address:
Street No., Apt. No. City, State Zip
Relationship to Proposed Insured: Social Security No.
(or Taxpayer ID No.):
15. Complete only if Spouse/Children (must be full time student if over
age 19) are Proposed for Insurance:
First Name, Middle Relationship to Birth
Initial and Last Name SSN No. Proposed Insured
Birth
Date Age Sex Ht. Wt.
16. Spouse's Occupation:_____________________________________ Birthplace
(state):___________________________ Income: $_________________ If
self-employed, income after expenses and before taxes:
$_________________ Driver's License Number: State of Issue:
17. Is spouse a U.S. citizen? [ ] Yes [ ] No If "No," date of
arrival in the U.S. ______________________________
Does spouse have an alien registration receipt "Permanent Visa"?
[ ] Yes [ ] No
If "Yes," Permanent Visa Number:____________________________________
18. Does spouse use tobacco in any form? [ ] Yes.
What form?__________________________ No. per day:_______
[ ]No. [ ] Never Used. [ ] Stopped on _____/_____/_____
19. Do all family members proposed for insurance live with the Proposed
Insured? [ ] Yes [ ] No If "No," explain and give name and phone
number where family member can be contacted _________________________
20. Plan Information
a. Plan of Insurance: ____________________________________ Premium
Amount:________________ $_______
b. [ ] Addition to Existing Policy No.: ___________________ $_______
Amount:________________ $
c. Death Benefit Option:
[ ] Option 1: Accumulation Value included in Specified Amount
[ ] Option 2: Accumulation Value in addition to Specified Amount
d. I elect the Automatic Premium Deduction Option.
(Not available with all plans) [ ]Yes [ ] No
Amount or No.
e. Riders: of Units (if applicable)
(Please Note: Not all
riders are available
with all plans)
Premium
[ ]Waiver of Premium or Disability __________________ $
[ ]Accidental Death Benefit __________________ $
[ ]Guaranteed Issue Benefit __________________ $
[ ]Children's Rider __________________ $
[ ]Spouse (indicate type of coverage) __________________ $
[ ]Additional Insured Rider (Self, Spouse) __________________ $
[ ]Other Insured Rider __________________ $
[ ]Other __________________ $
f. Amount Collected Explanation of Amount Collected Mode Total Premium
(Cash with App):
$ $
THIS BOX FOR ADMINISTRATIVE PURPOSES ONLY
21. List all Life Insurance now in force or pending on any Proposed
Insured(s). If none, write "None." Have you had or do you intend to have
any life insurance policy replaced, converted, reduced, reissued,
subjected to borrowing, or otherwise discontinued because of this
application? If "Yes," so indicate below.
Policy Face ADB To Be 1035
Company Number Amount Pending Amount Replaced, etc. Exchange?
_____________________________________________ [ ]Yes [ ]No [ ] Yes [ ] No
_____________________________________________ [ ]Yes [ ]No [ ] Yes [ ] No
_____________________________________________ [ ]Yes [ ]No [ ] Yes [ ] No
_____________________________________________ [ ]Yes [ ]No [ ] Yes [ ] No
_____________________________________________ [ ]Yes [ ]No [ ] Yes [ ] No
22. Life Insurance Beneficiary (Give full names and relationship).
Note: Unless you specify otherwise, payments will be shared equally by
all primary beneficiaries who survive the Insured or, if none, by all
contingent beneficiaries who survive the Insured. The right to change
the beneficiary is reserved unless otherwise stated.
[ ] attached Beneficiary Designation
Primary Beneficiary(ies)
Name Relationship SSN No.
Name Relationship SSN No.
Contingent Beneficiary(ies):
Name Relationship SSN No.
Name Relationship SSN No.
23. Complete only for PRD or Association Group or Franchise Coverage:
Full Name of Group/Organization_________________ Date Joined_________
Group/Membership No.: ____________Relationship to above:
[ ] Shareholding Member [ ] Dues-paying Member [ ] Other ______
PART II OF APPLICATION FOR LIFE INSURANCE - NONMEDICAL SUPPLEMENT
PLEASE PRINT. ALL QUESTIONS RELATE TO ANYONE PROPOSED FOR INSURANCE.
Wisconsin Residents: AIDS (HIV) test results received at an anonymous
counseling and testing site need not be disclosed.
1. Name, address and telephone number of personal physician of each person
proposed for insurance:
(a) Date last seen:
(b) State reason, findings and treatment:
2. Name and address of physician most recently consulted by each person
proposed for insurance: _______________
(a) Date:___________ (b) State reason, findings and treatment
3. Have you, or any person proposed for insurance, ever been told that you had,
or have you consulted or been treated by a physician or licensed practitioner
for any of the following:
YES NO
(a) Any disease or abnormal condition of the heart, circulatory system or
blood vessels, high blood pressure, rapid pulse, rheumatic fever, murmur,
coronary artery disease, chest pain, angina or stroke?
(b) Any disease of the lungs or respiratory system, including tuberculosis,
asthma, bronchitis, emphysema or shortness of breath?
(c) Any digestive system disease, including stomach or duodenal ulcer,
indigestion, stomach pain, liver or gallbladder disease, colon or rectal
disorder?
(d) Any genitourinary system disease including albumin, blood or sugar in
urine, kidney infection or stones, tumor or disease of the prostate,
testis, breasts, uterus or ovaries?
(e) Any nervous, brain or mental disorder, convulsions, dizziness,
headaches, epilepsy, nervous breakdown or paralysis?
(f) Any bone or joint disorder, arthritis or rheumatism, bodily deformity,
back or spinal disorder?
(g) Any disease or impairment of vision or hearing?
(h) Gout, diabetes, thyroid or other glandular disorder, cancer, tumor or
blood disorder other than AIDS or AIDS Related Complex (ARC).
4. Have you, or any person proposed for insurance, ever been diagnosed as
having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC),
caused by the HIV infection, or been treated for AIDS or ARC by a physician or
licensed practitioner?
5. During the past 10 years, have you, or any person
proposed for insurance: (a) had any illness, injury, surgery, hospitalization,
medical examination or care not listed above? (b) had or received treatment
for any unexplained fever, fatigue or chronic cough? (c) had any X-rays,
electrocardiograms, blood or other studies, except for an HIV test? (d) been
advised by a physician to have a surgical operation? (e) been advised by a
physician to limit your use of alcohol?
6. Are you, or any person proposed for insurance, now taking any medication
prescribed by a physician?
7. During the last 10 years, have you, or any person proposed for insurance:
(a) used alcohol or other drugs to a degree that required treatment or advice
from a physician or other licensed practitioner?
If "Yes," has use been discontinued?
(b) been or are currently a member of Alcoholics Anonymous or Narcotics
Anonymous?
8. If pregnant, enter approximate delivery date:________________________
9. Height: _______________ft.______________ins. Weight: _________________lbs.
Weight change during last 12 months: Lbs. Gained:___________ Lost:__________
10. Family Age if If Living, If Deceased, Age at
History Living Present Health Cause of Death Death
Father
Mother
Sibling
Sibling
Sibling
Sibling
11. Have you, or any person proposed for insurance: YES NO
(a) ever been declined, postponed, limited, denied reinstatement or
asked to pay an extra premium by any insurance company?
(b) engaged in any hazardous sports or activities such as motor vehicle
racing, boat racing, parachuting, hang gliding, skydiving, skin diving
or scuba diving within the last three years, or plan such activity in
the next six months?
(c) any intention of traveling or living outside the USA or Canada in
the next two years?
(If "Yes," complete foreign travel questionnaire.)
(d) flown as a civilian pilot, student pilot or crew member within the
last three years, or plan such activity in the next 12 months?
(If "Yes," complete Aviation Supplement).
(e) within the last 5 years: (1) been convicted of two or more
moving violations or driving under the influence of alcohol or drugs or
(2) had a driver's license suspended or revoked?
(f) been convicted of a felony within the last 10 years?
IF ANY OF THE ABOVE QUESTIONS ARE ANSWERED "YES," GIVE COMPLETE DETAILS IN
PART III
PART III OF APPLICATION FOR LIFE INSURANCE -
ADDITIONAL DETAILS AND EXPLANATIONS
(Use for any explanation where space is insufficient)
# Ques. Condition, Injury,
No. Name Symptom of Ill Health Mo. Degree of Name,
or Findings of and Yr. Duration Recovery Address,
Examination Zip of
(If Operation Hospital
Performed, State Type) and Attending
Physician
________________________________________________________________________________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
_________ _________ _____________________ __________________ ________ ________
ACKNOWLEDGEMENT. I received a Notice of Exchange of Information, a Fair Credit
Reporting Act Notice, a Notice of Information Practices, a Summary of Rights
Under the Fair Credit Reporting Act, and a Life Insurance Buyer's Guide before
completing this application.
AGREEMENTS. I, the undersigned, and the undersigned Agent(s)/Broker(s) certify
that we have read the completed application or have had it read to us and agree
to the following:
1. (This statement is only applicable to Variable Universal Life products.) I
understand that the policy's accumulation value in the Variable Account is based
on the investment experience in that account and will increase or decrease
daily. I understand that the amount of the death benefit may be fixed or
variable, depending on the investment experience of the Variable Account.
2. All answers in this application: (a) are true and complete to the best of my
knowledge and belief, (b) will be relied on to determine insurability and (c)
which are incorrect or misleading, may void the application effective the issue
date.
3. If the full initial premium is paid on the date of the completed life
insurance application and I am eligible for the policy applied for in accordance
with the underwriting standards of United of Omaha in effect on the date of the
application, the life policy will be in effect from the date of the application.
4. If any Proposed Insured for insurance is not eligible for the insurance
applied for, or if there has been any change in either my health or habits or
the answers to any of the questions in the application prior to policy delivery,
I agree that no policy of any kind will be in effect, except for coverage
provided by the Temporary Life Insurance Agreement and Receipt.
5. In no event will any benefits be paid for the same loss under both the
Temporary Life Insurance Agreement and Receipt and any policy issued from this
application.
6. If the Applicant is other than the Proposed Insured, the policy will be owned
by the Applicant.
7. No Agent/Broker can: (a) waive or change any receipt or policy provision or
(b) agree to issue a policy.
I have: (a) read the Agreements section and the receipt(s) and (b) read and
approved the answers as recorded.
Signed at____________ Date _________________________
City, State Signature of Proposed Insured(s) (Age 15 and Over)
____________________________________________________________________________
Signature of Parent or Guardian (if insured under age 15)
____________________________________________________________________________
Signature of Applicant/Owner/Trustee (if other than Proposed Insured)
___________________________________ ________ _________________________________
Signature of Agent/Broker Date Print or Stamp Agent/Broker Name
___________________________________ _________ ________________________________
Signature of Agent/Broker Date Print or Stamp Agent/Broker Name
AGENT/BROKER STATEMENT:
1. Do you have any reason to believe the policy applied for has replaced or
will replace any life insurance policy? (If "Yes," fulfill all state
requirements.) [ ] Yes [ ] No
2. In the presence of the Proposed Insured/Spouse have you asked each
question exactly as written and recorded the answers completely and
accurately? (If "No," explain.) [ ] Yes [ ] No
___________________________________ ________
Signature of Agent/Broker Date
___________________________________ ________
Signature of Agent/Broker Date
AGENT'S/BROKER'S REPORT
(MUST be completed by the agent/broker who obtained the application on the
Proposed Insured named below.)
1. Is Proposed Insured self-supporting? [ ] Yes [ ] No If "No," provide
the following information about the person on whom Proposed Insured is
dependent:
Full Name _______________________________ Address ____________________________
Birth Date Amount of insurance carried with all companies $ ____________ If
none, state why
2. If Proposed Insured used different name in past, give
previous full name
3. (a) Are you related to Proposed Insured or Owner?
[ ]Yes [ ] No
If "Yes," state relationship
(b) How long have you known Proposed Insured?
(c) How long have you known Proposed Owner?
4. When did you last see Proposed Insured?
5. Did you ask Proposed Insured or Owner every
question as printed (if "No," explain below)?
[ ] Yes [ ] No
6. Do you have any information not presented in this application which might in
any way affect this risk (if "Yes," explain below)?[ ] Yes[ ] No
7. Proposed Insured's Annual Income $ [ ]Exact [ ] Estimated
8. What is the purpose of this insurance? Give details including financial
information (for amounts of $500,000 or more, financial statements may be
requested)
9. (a) Is a medical exam to be completed? [ ] Yes [ ] No
(b) Name of examiner or paramedical facility
10. Previous residence and business addresses of Proposed Insured for past five
years.
Address From To
_____________________ ______________ ___________________
_____________________ ______________ ___________________
_____________________ ______________ ___________________
11. Is another policy requested based on this application? [ ] Additional
policy Plan[ ] Alternate policy Amount $ Owner (if different)
Beneficiary (if different)
12. Is Proposed Insured applying for insurance with any other company (if "Yes,"
give details)? [ ] Yes[ ]No
13. To the best of your knowledge will this policy replace any existing life
insurance or annuity (if "Yes," give details and fulfill all state
requirements)? [ ] Yes [ ] No
Details:
AGENT(S)/BROKER(S) TO RECEIVE COMMISSION AND VOLUME CREDIT FOR THIS APPLICATION
Agent's/Broker's Full Name Agent's/Broker's Production No. % Credit
1._________________________________________________________________________
2._________________________________________________________________________
I hereby certify that I have truly and accurately recorded the information
furnished by the Owner and/or Proposed Insured.
___________ ________________________________ ______________________________
Date Signature of Agent(s)/Broker(s) Agent('s)/Broker('s) Name
(Please Print)
_________________________________________________________________________
Name of Division Office/Wholesaler
_________________________________________________________________________
Name of Assistant Wholesaler (Brokerage Only)
Bank Service Plan Request Form
Complete the following information:
Insured's Name
Address
City
State ZIP
Coverage ID Number(s):
________________ _______
________________ _______
Specify Preferred Date of Withdrawals
Please indicate when you prefer the monthly premiums to be withdrawn from your
checking account:
Withdraw on the ________________ (1st through 28th) of the month
Bank Service Plan Authorization
As a convenience to me, I authorize Mutual of Omaha Insurance Company and/or its
affiliated Companies* to withdraw funds from my account.
I also authorize you, my financial institution, to pay from my account any
checks, drafts or preauthorized electronic fund transfers from my account to the
appropriate Company(ies) below. Your rights with each such charge will be the
same as if personally paid by me. This authorization will be effective until I
give you at least three business days' notice to cancel it. If notice is given
verbally, you may require written confirmation from me within 14 days after my
verbal notice.
__________________ ______________________________________
Date Authorized Signature as Shown on Account
______________________________________
Joint Account or Other Authorized Signature
*Mutual of Omaha Insurance Company - United of Omaha Life Insurance Company
United World Life Insurance Company - Mutual of Omaha Plaza - Omaha, Nebraska
68175 In New York, Companion Life Insurance Company - 401 Theodore Fremd Avenue
- - Rye, New York 10580-1493