Short-Term Disability

MUTUAL of OMAHA INSURANCE COMPANY THAT WORKS FOR ME. Disability Insurance Choice Portfolio Short-Term Disability Prepared for: Presented by: DOVETAIL SHORT & LONG TERM DI Home Office none 402-351-0000 Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Home Office Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 1 of 6

Short-Term Disability MUTUAL of OMAHA INSURANCE COMPANY Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-tobacco User / ST Benefit Period: 3 Months Premium Premium Includes Annual Premium Monthly Disability Benefit $3,600 (Includes Base Disability Benefit only) Base Disability Benefit $3,600 per month $ 951.21 Waiver of Premium Cost Total Premium After Savings if Applied Available Premium Savings Monthly BSP (Bank Service Plan) Premium $83.23 Quarterly Premium $247.31 Semi-Annual Premium $489.87 Annual Premium $951.21 (*Premium savings does not apply to this rider) te: 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. w 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 $10,800. Short-Term Disability - This policy pays the insured a monthly cash benefit of $3,600 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. Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office License Number: none Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 2 of 6

Short-Term Disability MUTUAL of OMAHA INSURANCE COMPANY Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-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 is unable to perform the material and substantial duties of their regular occupation; is not engaged in any occupation for wage or profit; 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. Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 3 of 6

MUTUAL of OMAHA INSURANCE COMPANY Short-Term Disability Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-tobacco User / ST Benefit Period: 3 Months Waiver of Premium 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: This proposal is not a contract. Please refer to your Outline of Coverage or contract for statespecific exclusions and limitations. (a) (b) (c) (d) (e) (f) (g) (h) (i) 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 resulting from Substance Abuse; or loss resulting from Mental or Nervous Disorders. Pregnancy: Benefits are not payable for loss due to rmal childbirth, rmal Pregnancy or voluntarily induced abortion. We will pay benefits for Complications of Pregnancy on the same basis as any other Sickness. Benefits payable for loss for which benefits are provided under any state or federal worker s compensation, employer s liability, or occupational disease law will be reduced by 50%. Exclusions and Limitations are different in CA, CT, NV, NY, PA, SD, VT and WA. Please ask your producer for an Outline. Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 4 of 6

Short-Term Disability MUTUAL of OMAHA INSURANCE COMPANY Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-tobacco User / ST Benefit Period: 3 Months 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 $8,100 and Above Interview, Long Form Paramed, Blood and Urine, EKG 2 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 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 Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 5 of 6

Short-Term Disability MUTUAL of OMAHA INSURANCE COMPANY Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-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 te: Net income (income less business expenses prior to taxes) is used for self-employed individuals; Gross income is used for salaried individuals. Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office Date: 07/21/2015 Version: 1.71 Policy Form: D82 Page: 6 of 6

Short-Term Disability MUTUAL of OMAHA INSURANCE COMPANY Proposed Insured: DOVETAIL SHORT & LONG TERM DI State of Issue: NE Age: 45 / Male / n-tobacco User / ST Benefit Period: 3 Months 1-Year Benefit Period 30-Day Elimination Period 50% Income Replacement 2-Year Benefit Period 30-Day Elimination Period Max Income Replacement AME Rider $1K 2-Year Benefit Period 14-Day Elimination Period Max Income Replacement AME Rider $5K Hospital Indemnity Rider Premium: $830.15 Premium: $1461.18 Premium: $2380.77 Each policy option comes with these benefits: Total/Partial Disability, Presumptive Total Disability, Transplant Donor, Terminal Illness, Survivor, Rehabilitation, Waiver of Premium, Recurrent Disability and Workers Compensation Rider. By choosing from these three options you will be provided with the coverage you need to secure the life you have built. ACCIDENT ONLY DISABILITY When it comes to Disability Insurance, there is not a one-sizefits-all solution. At Mutual of Omaha, we have tools to design a policy that fits your unique needs. Your lifestyle and dreams for your future depend on your ability to work and earn an income, we can help you protect it. Review the benefit options above to help you choose the right protection for you with a price that fits your budget. 2-Year Benefit Period 14-Day Elimination Period Max Income Replacement Total/Partial Disability Presumptive Total Disability Survivor Waiver of Premium Recurrent Disability Workers Compensation Rider Premium: $461.36

Client Input Summary Company: Product: Case: Mutual of Omaha - Health DI Choice v1.71 untitled.recovered July 21, 2015 6.124.0, 6.37.27 Client #1 Plan and Insured Plan Short-Term Disability Client Name DOVETAIL SHORT & LONG TERM DI Sex Male Age Last Birthday 45 Tobacco User Student Program Risk Class Standard Is client a Railroad Employee? Is client a Government Employee? Main Occupation Category ne Main Occupation Category Job Description Job Description Occupation Class 4A Annual Earned Income 65000 State Code NE State Disability Eligibility State Disability Amount Are you covered under CalSTRS or CalPERS? Self-Employed Savings - Financials Required Assocation Member Savings Common Employer Savings Life/DI Savings Benefit Period 3 Months Elimination Period 14 Days Premium and Benefit Options Premium Mode Premium Mode Type Is coverage to be puchased taxed? Group LTD Monthly Benefit Type Specified Amount Percent of Income Monthly Benefit Cap Individual LTD Monthly Benefit Type Specified Amount Percent of Income Annual Maximum Benefit Page 1 of 3

Client Input Summary Company: Product: Case: Mutual of Omaha - Health DI Choice v1.71 untitled.recovered July 21, 2015 6.124.0, 6.37.27 Client #1 Premium and Benefit Options - Cont'd Riders Total Monthly Benefit Total Monthly Benefit Amount Total Monthly Benefit Percentage Social Insurance Supplement Minimum SIS Benefit Maximize SIS Benefit Specify SIS Benefit SIS Benefit Amount ** Premium Result ** 951.21 Cost of Living Adjustment Extended Own-Occ Disability Extended Proportionate Rider Future Insurability Option Critical Illness Critical Illness Benefit Amount Hospital Confinement Indemnity Daily Room & Board Benefit Amount Return of Premium Rider Percentage Accident Medical Expense Rider Accident Medical Expense Benefit Amount Monthly Expenses Total Monthly Expense Only Ownership Percentage Total Monthly Expense Employee Salaries Interest on Loans Mortgage Interest Payments Insurance [casualty/liability] Property Taxes [real and personal] Depreciation [office equipment only] Rent [including land rental] Electricity Heat Water Telephone Postage and Stationery Equipment Rental Page 2 of 3

Client Input Summary Company: Product: Case: Mutual of Omaha - Health DI Choice v1.71 untitled.recovered July 21, 2015 6.124.0, 6.37.27 Client #1 Monthly Expenses - Cont'd Laundry Other Fixed Operating Expenses Optional Pages Print Values Page Alternate Premiums Good, Better, Best Yes Home Office For Home Office Use Only Producer Info Producer Name Home Office Producer License Number Producer Phone Number 402-351-0000 Page 3 of 3