Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage NEW YORK

Transcription

1 Mutual f Omaha Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska Applicatin Submissin Checklist T Mutual f Omaha Fr Medicare Supplement Cverage NEW YORK THIS APPLICATION MUST BE USED TO WRITE MUTUAL OF OMAHA MEDICARE SUPPLEMENT 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 Date in all places indicated. 5. Be sure t leave all applicable frms with the prpsed insured. 6. Cmplete the Cnditinal Receipt, with agent signature and prvide t client. 7. 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. 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 M26238_NY_0409) and return with the cmpleted applicatin. Prvide Ntice f Infrmatin Practices t cilent Cmplete Replacement Ntice - M _0605 and leave a cpy with the applicant (if applicable) Cmplete Medicare supplement Plan B Disclsure Agreement - M25152 and leave a cpy with the applicant (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. MAP525_NY_0910

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 Date Premium Cllected (Amunt) Initial Mde* (A=Annual, S=Semiannual, Q=Quarterly, r B=Autmatic Funds Withdraw) Renewal Premium (Amunt) Renewal Mde* (A=Annual, S=Semiannual, Q=Quarterly, r B=Autmatic Funds Withdraw) *Direct Mnthly billing nt available Part I 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. Part II Existing Cverage Infrmatin Please cmplete all questins in full. If the applicant is nt cvered by Medicare, indicate Eligibility Date and Date 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 Date Plicy/Certificate Number Terminatin/Disenrllment Date Plan Kind f Plicy Nte: 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 Mutual f Omaha Insurance Cmpany (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 & mntly 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), leave bth frms with applicant. 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 Grup number (if applicable): Applicatin Fr Medicare Supplement Cverage Mgr./Cmmissin Cde (Required Field Fr Brkerage) PLAN INFORMATION (t be cmpleted by Prducer) District Sales Manager/Assc. Marketer Applicatin Reviewed By Plan A Plan B Plan C Plan D Plan F Plan G Plan M Plan N NOTE: Fr ALL sectins, ONLY cmplete the infrmatin if t be insured. APPLICANT Plicy Frm Requested Effective Date APPLICANT B Plicy Frm Requested Effective Date Premium Cllected (based n age at applicatin date) $ Premium Cllected (based n age at applicatin date) $ Initial Mde A, S, Q, B, ACH Initial Mde A, S, Q, B, 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. 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 Date f Birth m day yr Male Female Scial Security N Medicare Health Insurance Card Number (if knwn) If yu are cvered under Medicare Part A, please list yur effective date If NO, please indicate yur eligibility date If yu are cvered under Medicare Part B, please list yur effective date If NO, please indicate date yu plan t enrll Address Have yu received a cpy f the Guide t Health Insurance fr Peple with Medicare and the Outline f Cverage? Yes N Hme Phne N ( ) (area cde) Current Age Date f Birth m day yr Male Female Scial Security N Medicare Health Insurance Card Number (if knwn) If yu are cvered under Medicare Part A, please list yur effective date If NO, please indicate yur eligibility date If yu are cvered under Medicare Part B, please list yur effective date If NO, please indicate date yu plan t enrll Address Have yu received a cpy f the Guide t Health Insurance fr Peple with Medicare and the Outline f Cverage? Yes N MA P.O. Bx 3608 Omaha, Nebraska

4 2. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS. nte: The sale f a Medicare supplement plicy is prhibited where an individual has a Medicare supplement plicy in frce and des nt desire t replace the existing plicy r where the Medicare supplement plicy wuld duplicate benefits t which the individual is entitled under a Medicare Advantage plan. T the Best f Yur Knwledge and Belief: 1. Did yu turn age 65 in the last six mnths? 2. Did yu enrll in Medicare Part B in the last six mnths? If YES, indicate yur effective date. / 3. 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 Name f Cmpany Yes N Yes N Yes N Yes N Yes N Yes N Plicy/Certificate Number Plan Plicy/Certificate Number Plan Issue Date Issue Date (b) If YES, d yu intend t replace yur current Medicare supplement plicy/certificate with this plicy? (c) If YES, indicate terminatin date. / Yes N Yes N 4. If yu had cverage frm any Medicare Advantage plan ther than riginal Medicare within the past 63 days (fr example, a Medicare HMO, PPO r PFFS), fill in yur start and end dates belw. If yu are still cvered under this plan, leave END blank. START END / START END (a) If yu are still cvered under the Medicare Advantage plan, d yu intend t replace yur current cverage with this new Medicare supplement plicy? Yes N Yes N (b) Planned date f terminatin/disenrllment? / (c) Was this yur first time in this type f Medicare Advantage plan? (d) Did yu drp a Medicare supplement r Medicare select plicy/certificate t enrll in this Medicare Advantage plan? Yes Yes N N Yes Yes N N 5. 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 Name f Cmpany 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 (c) Planned date f terminatin/disenrllment? / MA P.O. Bx 3608 Omaha, Nebraska

5 6. 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? 3. PLEASE READ AND SIGN BELOW Yes N Yes N Yes N Yes N Yes N Yes N 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 t the best f my knwledge and belief. 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 Mutual f Omaha Insurance Cmpany. Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin, r cnceals fr the purpse f misleading, infrmatin cncerning any fact material theret, cmmits a fraudulent insurance act, which is a crime and shall als be subject t civil penalty nt t exceed five thusand dllars and the stated value f the claim fr each such vilatin. Dated at, n, City State Mnth Day Year s Signature Dated at, n, City State Mnth Day Year 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 MA P.O. Bx 3608 Omaha, Nebraska

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 Name f Cmpany Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage (b) List plicies sld in the past five (5) years which are n lnger in frce. Name f Cmpany Name f Cmpany Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage SECTION FOR ADDITIONAL COMMENTS (please attach a separate sheet if needed) Plicy/Certificate Number Descriptin f Benefits Effective Date f Cverage (please attach a separate sheet if needed) MA P.O. Bx 3608 Omaha, Nebraska

7 Mutual f Omaha Insurance Cmpany Plicy Delivery Mail plicy/plicies t: a) Prducer 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.

8 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 Date: 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 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 premium by ACH and renewal premiums by direct billing (annually, semiannually, r quarterly), 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 premium 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 can nt 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 ACH/BSP frm accurately and in its entirety, making sure that all required infrmatin is crrect and cmplete n yur ACH/BSP frm prir t submissin. In additin, please make sure that the premium amunt is filled in n the ACH/BSP 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. M26238_NY_0409

9 Mutual f Omaha Insurance Cmpany r United Wrld Life Insurance Cmpany 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 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 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 Mutual f Omaha and/r United Wrld Life Insurance Cmpany t withdraw funds frm my accunt fr my initial and/r mnthly renewal premiums and understand that the amunts may differ. I als authrize Mutual f Omaha and/r United Wrld Life Insurance Cmpany 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 Mutual f Omaha and/r United Wrld Life Insurance Cmpany. 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 Date Authrized Signature as Shwn n Accunt Date M26238_NY_0409

10 Mutual f Omaha Insurance Cmpany Ntice t Regarding Replacement f Accident and Health Insurance, HMO Cverage r Emplyer-Prvided Health Benefit Arrangement Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing accident and health insurance, health maintenance rganizatin cverage r emplyer-prvided health benefit cverage and replace it with a plicy (certificate) t be issued by Mutual f Omaha Insurance Cmpany. Yur new plicy (certificate) will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy (certificate). Yu shuld review this new cverage carefully. Cmpare it with all health cverage yu nw have and evaluate the need fr existing cverage that may duplicate this plicy (certificate). Terminate yur present cverage nly if, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin. Statement t by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. The replacement f insurance invlved in this transactin (des) (des nt) duplicate cverage, t the best f my knwledge. The replacement plicy is being purchased fr the fllwing reasn(s) checked belw: 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) If yu still wish t terminate yur present plicy r certificate and replace it with new cverage, review the applicatin carefully befre yu sign it t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy (certificate) until yu have received yur new plicy (certificate) and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative* Mutual f Omaha Insurance Cmpany, Mutual f Omaha Plaza, Omaha, NE ( s Signature) *Signature nt required fr direct respnse sales. (Date) 1 - Hme Office Cpy M _0605

11 Mutual f Omaha Insurance Cmpany Medicare Supplement Plan B Disclsure Agreement I understand I (am purchasing / have purchased) Medicare supplement Frm MM21 (Plan B Optin) frm Mutual f Omaha Insurance Cmpany. I am fully aware that I may purchase cverage at any time under Medicare supplement Frm MM25 (Plan G Optin) which has greater benefits at a similar rate. Signature Date 1 - Hme Office Cpy M25152

12 IMPORTANT DOCUMENTS CLIENT FORMS As part f the applicatin prcess, the applicant has signed multiple frms. cpies f these frms and client ntificatins n the fllwing pages are t be given t the applicant if applicable. Replacement Ntice (If replacing, bth yu and the applicant must sign the custmer cpy f the replacement ntice) Ntice f Infrmatin Practices Medicare Supplement Plan B Disclsure Agreement Please als prvide the client(s) with the Cnditinal Receipt, lcated in Sectin 4 f the applicatin.

13 Mutual f Omaha Insurance Cmpany Ntice t Regarding Replacement f Accident and Health Insurance, HMO Cverage r Emplyer-Prvided Health Benefit Arrangement Save this ntice! It may be imprtant t yu in the future. Accrding t yur applicatin, yu intend t terminate existing accident and health insurance, health maintenance rganizatin cverage r emplyer-prvided health benefit cverage and replace it with a plicy (certificate) t be issued by Mutual f Omaha Insurance Cmpany. Yur new plicy (certificate) will prvide thirty (30) days within which yu may decide withut cst whether yu desire t keep the plicy (certificate). Yu shuld review this new cverage carefully. Cmpare it with all health cverage yu nw have and evaluate the need fr existing cverage that may duplicate this plicy (certificate). Terminate yur present cverage nly if, after due cnsideratin, yu find that purchase f this Medicare supplement cverage is a wise decisin. Statement t by Issuer, Agent, Brker r Other Representative: I have reviewed yur current medical r health insurance cverage. The replacement f insurance invlved in this transactin (des) (des nt) duplicate cverage, t the best f my knwledge. The replacement plicy is being purchased fr the fllwing reasn(s) checked belw: 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) If yu still wish t terminate yur present plicy r certificate and replace it with new cverage, review the applicatin carefully befre yu sign it t be certain that all infrmatin has been prperly recrded. D nt cancel yur present plicy (certificate) until yu have received yur new plicy (certificate) and are sure that yu want t keep it. Signature f Agent, Brker r Other Representative* Mutual f Omaha Insurance Cmpany, Mutual f Omaha Plaza, Omaha, NE ( s Signature) *Signature nt required fr direct respnse sales. (Date) 2 - Cpy M _0605

14 Mutual f Omaha Insurance Cmpany Mutual f Omaha Insurance Cmpany - 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: MUTUAL OF OMAHA INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, MUTUAL OF OMAHA PLAZA, OMAHA, NE Give this ntice t the applicant.

15 Mutual f Omaha Insurance Cmpany Medicare Supplement Plan B Disclsure Agreement I understand I (am purchasing / have purchased) Medicare supplement Frm MM21 (Plan B Optin) frm Mutual f Omaha Insurance Cmpany. I am fully aware that I may purchase cverage at any time under Medicare supplement Frm MM25 (Plan G Optin) which has greater benefits at a similar rate. Signature Date 2 - Cpy M25152

16 4. CONDITIONAL RECEIPT Mutual f Omaha Plaza Omaha, Nebraska All checks fr premiums must be made payable t Mutual f Omaha Insurance Cmpany. D nt make checks payable t the prducer r leave the payee blank. Received frm the sum f $ paid as the full initial premium with the attached insurance applicatin t Mutual f Omaha Insurance Cmpany. Mutual f Omaha Insurance Cmpany agrees that insurance shall becme effective as f the date f the applicatin (r a later date if s requested by the applicant), if the applicant, as f the date f the applicatin, is insurable and acceptable fr said insurance under its usual underwriting rules, and the required premium has been paid. If the applicant des nt qualify accrding t the Cmpany s current underwriting rules n the date the premium is taken, n cverage is in effect, n plicy will be issued and premium will be refunded. Shuld Mutual f Omaha Insurance Cmpany decline t issue the insurance applied fr, I hereby agree t return the abve sum t the Prpsed Insured(s). (Date) (Prducer) Cmplete receipt in full and leave with applicant MA P.O. Bx 3608 Omaha, Nebraska