APPLICATION for INDIVIDUAL LONG-TERM CARE

Mutual of Omaha Isurace Compay APPLICATION for INIVIUAL LONG-TERM CARE ILLINOI Mutual of Omaha Isurace Compay Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com MAP194_IL

Log-Term Care Isurace Applicatio ubmissio Checklist for Producers * To prequalify your applicat(s), call 800-551-2059. * After completig this applicatio, you, the producer, should call 866-544-1617 to iitiate the Persoal Health Iterview. ubmit the fully completed applicatio, ad applicable completed forms. Uaswered questios o the applicatio or missig or icomplete forms will result i uderwritig delays as we attempt to secure the iformatio. If a questio does ot apply to your cliet, aswer it as No or Noe rather tha N/A. If the applicat aswers Yes to ay questio i ectio, he/she is ieligible for coverage. Iform your cliet(s) that we will coduct a telephoe iterview or face to face iterview. Provide them a copy of Preparig for the Health Iterview. Log-Term Care Isurace Persoal Worksheet Complete, sig ad submit with applicatio. This worksheet helps determie whether a Log-Term Care policy is suitable. I order to esure that the applicatio is completed correctly, please use the followig istructios: Applicatio 1. ectios A-F must be aswered i full. Notes: Ay chages must be iitialed. Check height/weight build chart to esure cliet eligibility. 2. Choose to complete either ectio G or H. 3. ectio I - Eter the amout of premium ad billig mode. Notes: At least two moths premium must be submitted with mothly mode. If aother mode is selected, submit applicable premium for that mode. There is o policy fee. 4. ectios J-K must be aswered i full. Required Forms to be submitted with Applicatio Authorizatio to isclose Persoal Iformatio (HIPAA) Producer tatemet Either a Coditioal Receipt or Temporary Isurace Agreemet ad Receipt ( Agreemet ) Log-Term Care Isurace Replacemet (if applicable) Foreig Natioal ad Foreig Travel Questioaire (if applicable) Other tate pecial Forms (if applicable) Required Forms left with Applicat(s) Copy of either a Coditioal Receipt or Temporary Isurace Agreemet ad Receipt ( Agreemet ) MIB Group, Ic. Pre-Notice, Compay Notice of Iformatio Practices ad Ivestigative Cosumer Reports Notice Log-Term Care Isurace Potetial Rate Icrease isclosure Form Thigs You hould Kow Before You Buy Log-Term Care Isurace eior Health Couselig Notice (if applicable) Other tate pecial Forms (if applicable) Outlie(s) of Coverage LTC hopper s Guide Guide to Medicare for People Age 65 ad Older

Log-Term Care Isurace Persoal Worksheet Mutual of Omaha Isurace Compay Mutual of Omaha Plaza, Omaha, Nebraska 68175 People buy log-term care isurace for may reasos. ome do ot wat to use their ow assets to pay for log-term care. ome buy isurace to make sure they ca choose the type of care they get. Others do t wat their family to have to pay for care or do t wat to go o Medicaid. But log-term care isurace may be expesive, ad may ot be right for everyoe. By state law, the isurace compay must fill out part of the iformatio o this worksheet ad ask you to fill out the rest to help you ad the compay decide if you should buy this policy. Premium Iformatio Policy Form Number(s) LTC09M Type of Policy: Guarateed Reewable Nocacellable igle Premium Applicat A Applicat B The premium for the coverage you are cosiderig will The premium for the coverage you are cosiderig will be $ per moth, or $ per year be $ per moth, or $ per year or a oe-time sigle premium of $ or a oe-time sigle premium of $ The Compay s Right to Icrease Premiums The compay has a right to icrease premiums o this policy form i the future, provided it raises rates for all policies i the same class i this state. Oce your policy is paid up, the compay caot raise your rates. Rate Icrease History The compay has sold log-term care isurace sice 1987 ad has sold this policy form sice 2009. The compay has ot raised its premium rates o this policy form, but has o similar policy forms. The followig is a summary of the rate icreases for comprehesive coverage that the compay has sold. Policy Form* Years Available for Purchase Rate History NH23/NH24 1987-1993 No Rate Icrease LTC1/LTM1 1992-1997 No Rate Icrease LT50/NH50 1997-2004 No Rate Icrease NHA/LTA/HCA 1998-2004 23% overall rate icrease 2003 LTC04I 2004-2009 No Rate Icrease LTC04I7 2006-2009 No Rate Icrease LTC09M 2009 - Preset No Rate Icrease The rate icreases listed above represet the overall comprehesive rate icreases filed atioally i 2003. The availability, rate icrease amouts, ad dates of approvals vary by state. *Or state equivalet. M26681 ubmit to LTC ervice Office

Questios Related to Your Icome Applicat A 1. How will you pay each year s premium? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay 2. Have you cosidered whether you could afford to keep this policy if the premiums wet up, for example, by 20%? This is ot applicable to sigle premium. 3. What is your aual icome? (Check oe) Uder $16,000 $16,000 ad over 4. How do you expect your icome to chage over the ext 10 years? (Check oe) No Chage Icrease ecrease M26681 ubmit to LTC ervice Office Applicat B 1. How will you pay each year s premium? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay 2. Have you cosidered whether you could afford to keep this policy if the premiums wet up, for example, by 20%? This is ot applicable to sigle premium. 3. What is your aual icome? (Check oe) Uder $16,000 $16,000 ad over 4. How do you expect your icome to chage over the ext 10 years? (Check oe) No Chage Icrease ecrease If you will be payig premiums with moey received oly from your ow icome, a rule of thumb is that you may ot be able to afford this policy if the premiums will be more tha 7% of your icome. 5. Will you buy iflatio protectio? (Check oe) Yes No If ot, have you cosidered how you will pay for the differece betwee future costs ad your daily beefit amout? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay 5. Will you buy iflatio protectio? (Check oe) Yes No If ot, have you cosidered how you will pay for the differece betwee future costs ad your daily beefit amout? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay The atioal average aual cost of ursig home care i 2008 was $64,605, but this figure varies across the coutry. I te years the atioal average aual cost would be about $105,234 if costs icrease 5% aually. 6. What elimiatio period are you cosiderig? 6. What elimiatio period are you cosiderig? Number of days Number of days Approximate cost $ for that period of care. Approximate cost $ for that period of care. Multiply the umber of days with daily average for approximate cost of care. Referece cost of care sheet for state averages. 7. How are you plaig to pay for your care durig the elimiatio period? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay 7. How are you plaig to pay for your care durig the elimiatio period? (Check oe) From my Icome From my avigs/ivestmets My Family will Pay Questios Related to Your avigs ad Ivestmets Applicat A Applicat B 1. Not coutig your home, about how much are 1. Not coutig your home, about how much are all your assets (your savigs ad ivestmets) all your assets (your savigs ad ivestmets) worth? (Check oe) worth? (Check oe) Uder $50,000 Uder $50,000 $50,000 ad over $50,000 ad over 2. How do you expect your assets to chage over the ext 10 years? (Check oe) tay about the same Icrease ecrease 2. How do you expect your assets to chage over the ext 10 years? (Check oe) tay about the same Icrease ecrease If you are buyig this policy to protect your assets ad your assets, ot coutig your home, are less tha $50,000, you may wish to cosider other optios for fiacig your log-term care.

isclosure tatemet Applicat A (must check oe) The aswers to the questios o this Persoal Worksheet describe my fiacial situatio. OR I choose ot to complete this iformatio. You may be cotacted by a compay represetative to cofirm your decisio. Applicat B (must check oe) The aswers to the questios o this Persoal Worksheet describe my fiacial situatio. OR I choose ot to complete this iformatio. You may be cotacted by a compay represetative to cofirm your decisio. Applicat A THI BOX MUT BE CHECKE I ackowledge that the carrier ad/or its producer (below) has reviewed this form with me icludig the premium, premium rate icrease history ad potetial for premium icreases i the future. I uderstad the above disclosures. I uderstad that the rates for this policy may icrease i the future. X Applicat B THI BOX MUT BE CHECKE I ackowledge that the carrier ad/or its producer (below) has reviewed this form with me icludig the premium, premium rate icrease history ad potetial for premium icreases i the future. I uderstad the above disclosures. I uderstad that the rates for this policy may icrease i the future. X igature of Applicat A ate igature of Applicat B ate I explaied to the applicat(s) the importace of completig this iformatio. Prited Name of Producer X igature of Producer ate Authorizatio to Proceed whe Icome less tha $16,000 or Assets less tha $50,000 Applicat A Applicat B My producer has advised me that this policy does My producer has advised me that this policy does ot seem to be suitable for me. However, I still ot seem to be suitable for me. However, I still wat the compay to cosider my applicatio. wat the compay to cosider my applicatio. X X igature of Applicat A ate igature of Applicat B ate M26681 ubmit to LTC ervice Office

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Idividual Log-Term Care Isurace Applicatio Mutual of Omaha Plaza, Omaha, NE 68175 ubmit Applicatio To: Log-Term Care ervice Office, P.O. Box 64901, t. Paul, MN 55164-0901 Overight ubmissio: Log-Term Care ervice Office, 7805 Hudso Rd., te. 180, Woodbury, MN 55125-1591 New Busiess Reistatemet If posored/associatio, List Name ad ervice Group Number ectio A Applicat A GENERAL INFORMATION Applicat B 1 Name: 1 Name: Last Name Last Name First Name Middle Iitial First Name Middle Iitial 2 Legal Residece Address: 2 Legal Residece Address (If ifferet tha Applicat A): Number, treet, Apartmet Number Number, treet, Apartmet Number City, tate, ZIP Code City, tate, ZIP Code 3 Cotact Iformatio: 3 Cotact Iformatio (If ifferet tha Applicat A): ( ) ( ) ( ) ( ) aytime Phoe Number Eveig Phoe Number aytime Phoe Number Eveig Phoe Number : a.m. : p.m. : a.m. : p.m. Best Time to Call Best Time to Call E-mail Address E-mail Address 4 ocial ecurity Number: 4 ocial ecurity Number: 5 Birth ate, Age ad Geder: 5 Birth ate, Age ad Geder: // Moth ay Year Age Male Female // Moth ay Year Age Male Female 6 Occupatio ad uties: 6 Occupatio ad uties: Occupatio Occupatioal uties Occupatio Occupatioal uties THE POLICY I NOT APPROVE FOR MEICAI AET PROTECTION UNER THE ILLINOI LONG-TERM CARE PARTNERHIP PROGRAM. HOWEVER, THI POLICY I AN APPROVE LONG-TERM CARE POLICY UNER TATE INURANCE REGULATION. FOR INFORMATION ABOUT POLICIE AN CERTIFICATE APPROVE UNER THE ILLINOI LONG-TERM CARE PARTNERHIP PROGRAM, CALL THE ENIOR HELPLINE AT THE EPARTMENT OF AGING AT 1-800-252-8966. MA5933-11 ubmit to LTC ervice Office 1 IL

ectio A Applicat A GENERAL INFORMATION (cotiued) Applicat B 7 U.. Citizeship: 7 U.. Citizeship: Are you a citize of the Uited tates? Yes No If No, do you have a Permaet Residet Card Form I-551 (also kow as a Alie Registratio Receipt Card or Gree Card )? Are you a citize of the Uited tates? Yes No If No, do you have a Permaet Residet Card Form I-551 (also kow as a Alie Registratio Receipt Card or Gree Card )? Yes. Card Number ad ate of Arrival i the U.. Yes. Card Number ad ate of Arrival i the U.. No. You are ot eligible for this coverage. No. You are ot eligible for this coverage. 8 Beeficiary: 8 Beeficiary (If ifferet tha Applicat A): First Name, Middle Iitial, Last Name Number, treet, Apartmet Number City, tate, ZIP Code Relatioship to you ectio B ALLOWANCE You may be eligible for allowaces based o your aswers to the followig questios i this ectio B. First Name, Middle Iitial, Last Name Number, treet, Apartmet Number City, tate, ZIP Code Relatioship to you Applicat A Applicat B Yes No Yes No 1 Are you married?... o you have a omestic Parter*?... If No, go to questio 2. If Yes, : (a) Is your pouse or omestic Parter also applyig for this coverage? If Yes, provide ame... (b) oes he/she have a existig Mutual of Omaha Isurace Compay or Uited of Omaha Life Isurace Compay log-term care policy/certificate?... If Yes, provide existig log-term care policy/certificate umber(s)... 2 Are you sigle ad have you bee cotiuously residig with aother perso for the last 12 moths ad are they also applyig for this coverage? If Yes, provide ame... 3 o you have or are you applyig for a Medicare upplemet policy/ certificate with Mutual of Omaha Isurace Compay, Uited of Omaha Life Isurace Compay or Uited World Life Isurace Compay?... If Yes, provide existig policy/certificate umber(s)... 4 Are you a member, or qualified family member, of a posored/ Associatio group edorsig this log-term care product?... If Yes, provide posored/associatio ervice Group Number Full Name of Orgaizatio Name ad Relatioship to Member * omestic Parter meas either of the followig: (a) a adult perso with whom you have registered or filed for domestic partership i a civil uio with a govermet agecy or office where such registratio is available, or (b) a adult perso who meets the followig criteria: (1) has a serious ad committed persoal relatioship with you that is iteded to be lifelog, (2) has shared a commo permaet residece o a cotiuous basis with you for the most recet three years, ad (3) is ot married or legally separated, a omestic Parter to ayoe else or related to you i ay way that would bar marriage i the state where you ad he or she reside. MA5933-11 ubmit to LTC ervice Office 2

ectio C REPLACEMENT COVERAGE Provide Replacemet Coverage Iformatio. Applicat A Applicat B 1 o you curretly have aother log-term care isurace policy/certificate i force (icludig Yes No Yes No health care service cotracts or health maiteace orgaizatio cotracts)?... 2 id you have aother log-term care isurace policy/certificate i force durig the last 12 moths? 3 o you ited to replace other log-term care coverage or ay of your medical or health isurace coverage with this policy?... If Yes, please read ad sig the Notice to Applicat Regardig Replacemet form icluded with this applicatio. 4 Questio to be aswered by the Producer: Have you, the Producer, sold ay health isurace, icludig log-term care policies, to Applicat A or Applicat B which: are still i force; or were sold i the last five years but are o loger i force? 5 Applicat A B If ay questio 1-4 was aswered Yes, i the above ectio C, please provide details i C5 below. (Attach additioal siged page(s) if more space is eeded.) Compay Name/Address Policy/ Certificate # Pla Type * $ aily or Mothly Beefit tatus of Policy/Certificate Pedig I Force Termiated Lapsed Edig ate / / $ Aual Premium To be Replaced by this Coverage Yes No old by this Producer Yes No A B $ Pedig I Force Termiated Lapsed Edig ate / / $ Yes No Yes No A B $ Pedig I Force Termiated Lapsed Edig ate / / $ Yes No * Provide Pla Type abbreviatio: LTC=Log-Term Care, M=Medicare upplemet, MM=Major Medical, OH=Other Health Yes No 6 Have you ever bee declied, rated, or deied reistatemet for log-term care isurace?... If Yes, provide details below. (Attach additioal siged page(s) if more space is eeded.) Applicat Compay Name(s) Whe Why A B A B Applicat A Applicat B Yes No Yes No MA5933-11 ubmit to LTC ervice Office 3

ectio HEALTH INURABILITY QUETION If you aswer Yes to ay of the questios i this ectio, we are uable to accept this applicatio or offer you Log-Term Care Isurace. o ot cotiue. Applicat A Applicat B Yes No Yes No 1 o you curretly use ay of the followig:... wheelchair walker ebulizer electric scooter quad cae oxyge 2 Withi the past 6 moths have you bee cofied to, or bee advised to have, ay of the followig:... residetial care, assisted livig or adult day care facility services ursig home or home health care services physical, occupatioal or speech therapy 3 o you require the assistace or supervisio of aother perso or a device of ay kid for ay of the followig:... bathig toiletig dressig eatig medicatio maagemet gettig i ad out of a chair or bed your iability to cotrol your bowel or bladder 4 Have you ever had, bee diagosed as havig, or received medical advice or medical care from a physicia or health care provider for ay of the followig:... Alzheimer s isease Amyotrophic Lateral clerosis (AL) Chroic Hepatitis emetia Hutigto s Chorea Cirrhosis Memory Loss Kidey Failure or received ialysis Myastheia Gravis Metal Retardatio Parkiso s isease Paralysis chizophreia Multiple clerosis cleroderma Psychosis Muscular ystrophy ystemic Lupus Orga Trasplat Miistroke or Trasiet Ischemic Attack (TIA) i the past year, sigle episode stroke i the past 2 years, two or more strokes or TIAs, or you have ot fully recovered or cotiue to have weakess, decreased sesatio or loss of fuctio from a stroke or TIA iabetes ad curretly takig more tha 50 uits of isuli daily, or with peripheral europathy, umbess, tiglig or decreased sesatio i your feet, retiopathy or history of a stroke, miistroke or a TIA Cacer (except basal or squamous cell ski cacers, or stage I/A bladder, thyroid, breast or prostate cacers) i the past 2 years Chroic Obstructive Pulmoary isease (COP), Emphysema or Chroic Brochitis ad have used tobacco i the past year 5 Have you bee diagosed or treated by a member of the medical professio as havig Acquired Immue eficiecy ydrome (AI), AI Related Complex (ARC) or Huma Immuodeficiecy Virus (HIV) Ifectio (symptomatic or asymptomatic)?... 6 Are you curretly eligible for beefits uder, or covered by, Medicaid (ot Medicare), disability icome, workers compesatio, ocial ecurity disability or ay federal or state disability pla?... MA5933-11 ubmit to LTC ervice Office 4

ectio E PRIMARY CARE PHYICIAN INFORMATION AN MEICATION 1 Provide the ame, complete address ad phoe umber of your Primary Care Physicia. Applicat A Applicat B (If ifferet tha Applicat A) Primary Care Physicia Address City, tate, ZIP Phoe Number 2 ate & Reaso for Last Visit: Applicat A Applicat B 3 Are you takig or have you take ay prescriptio medicatio(s) withi the past 12 moths, or are you curretly takig ay over-the-couter medicatio(s) o a weekly basis or more frequetly?... If Yes, please list below all the medicatio ame(s) usig pharmacy label, dosage/ frequecy ad reaso prescribed. (Attach additioal siged page(s) if more space is eeded.) Medicatio Name osage/frequecy isease/isorder/coditio Applicat A Applicat B Yes No Yes No Medicatio Name osage/frequecy isease/isorder/coditio Medicatio Name osage/frequecy isease/isorder/coditio Medicatio Name osage/frequecy isease/isorder/coditio Medicatio Name osage/frequecy isease/isorder/coditio Medicatio Name osage/frequecy isease/isorder/coditio Medicatio Name osage/frequecy isease/isorder/coditio MA5933-11 ubmit to LTC ervice Office 5

ectio F AITIONAL HEALTH QUETION 1 o you have, or have you ever received ay advice, treatmet, cosultatio or diagosis from a physicia or health care provider for ay of the followig coditios? Alcohol or rug Use... Aemia or Blood isease/isorder... Arthritis, Back, Boe or Joit isorder or Broke Boes... Balace isorder, ifficulty Walkig or Falls... Bowel or Bladder isease/isorder... Cacer... Circulatory isease/isorder... epressio or other Metal isorder... iabetes... izziess or Faitig... Fibromyalgia, Weakess or Fatigue... Heart isease/isorder or High Blood Pressure... Immue ystem isease/isorder... Kidey or Liver isease/isorder... Neurological isease/isorder... Osteoporosis... Respiratory isease/isorder... eizures, Epilepsy or Tremors... Visio isorder... Applicat A Applicat B Yes No Yes No 2 Have you received ipatiet or outpatiet treatmet at a hospital, surgical ceter or rehabilitatio facility i the past 12 moths?... 3 Are you scheduled for, or have you bee advised by a physicia or health care provider to have additioal testig, surgery or cosultatio(s) to evaluate your health?... 4 Are there ay pedig test results which you have ot yet received?... 5 Have you bee see by your physicia, health care provider or ay specialist more tha three times i the past 12 moths?... 6 o you have, for your use, a hadicap parkig sticker or hadicap licese plate?... 7 Have you used tobacco i ay form i the past 2 years?... 8 What is your height?... 9 What is your weight?... lbs lbs MA5933-11 ubmit to LTC ervice Office 6

ectio F AITIONAL HEALTH QUETION (cotiued) If Yes to ay additioal health questios of ectio F, please provide the followig for each Yes aswer below. (Attach additioal siged page(s) if more space is eeded.) Applicat A isease/isorder/coditio ate of Occurrece ate of Last Visit Physicia/Facility Iformatio Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # Applicat B isease/isorder/coditio ate of Occurrece ate of Last Visit Physicia/Facility Iformatio Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # Name Address City, tate, ZIP Code Phoe # MA5933-11 ubmit to LTC ervice Office 7

INTRUCTION: Complete ectio G for MUTUAL CARE 3 or MUTUAL CARE 5 OR ectio H for MUTUAL CARE MY WAY. INFLATION PROTECTION: You have the optio to purchase a 5% Compoud Iflatio Protectio (Lifetime) beefit. Neither MUTUAL CARE 3 or MUTUAL CARE 5 offer the 5% Compoud Iflatio Protectio (Lifetime) beefit. If you wat to purchase this beefit KIP ectio G ad complete ectio H for MUTUAL CARE MY WAY. Check the first box i H7. ectio G MUTUAL CARE 3 OR MUTUAL CARE 5 Applicat A Applicat B (If selectig pouse hared Care Beefit, beefits must be idetical to Applicat A) 1 elect Mutual Care 3 or Mutual Care 5 1 elect Mutual Care 3 or Mutual Care 5 (must check oe): (must check oe): Mutual Care 3 Mothly Beefit (MMB) Mutual Care 5 Mothly Beefit (MMB) Mutual Care 3 Mothly Beefit (MMB) Mutual Care 5 Mothly Beefit (MMB) 2 Ackowledgemet (must check): 2 Ackowledgemet (must check): I ackowledge that by checkig this box, the 5% Compoud Iflatio Protectio (Lifetime) is NOT icluded: I have reviewed the Outlie of Coverage ad the graphs that compare the beefits ad premiums of this policy with ad without optio. pecifically, I have reviewed the optio for (Lifetime) optio. I ackowledge that by checkig this box, the 5% Compoud Iflatio Protectio (Lifetime) is NOT icluded: I have reviewed the Outlie of Coverage ad the graphs that compare the beefits ad premiums of this policy with ad without optio. pecifically, I have reviewed the optio for (Lifetime) optio. 3 Maximum Mothly Beefit (MMB) (must eter): 3 Maximum Mothly Beefit (MMB) (must eter): $, per moth ($3,000-$15,000 i $500 icremets) 4 Noforfeiture Beefit horteed Beefit Period (must check YE or NO ): YE NO, Noforfeiture Beefit horteed Beefit Period optio is NOT desired: I have reviewed the Outlie of Coverage ad compared the beefits ad premiums of this policy with ad without the Noforfeiture Optio(s) that have bee made available ad I reject the Noforfeiture Beefit horteed Beefit Period optio that is available. $, per moth ($3,000-$15,000 i $500 icremets) 4 Noforfeiture Beefit horteed Beefit Period (must check YE or NO ): YE NO, Noforfeiture Beefit horteed Beefit Period optio is NOT desired: I have reviewed the Outlie of Coverage ad compared the beefits ad premiums of this policy with ad without the Noforfeiture Optio(s) that have bee made available ad I reject the Noforfeiture Beefit horteed Beefit Period optio that is available. OPTIONAL BENEFIT FOR MUTUAL CARE 3 OR MUTUAL CARE 5 5 pouse hared Care Beefit 5 Oly available whe both pouses or omestic Parters apply at the same time ad both policies are issued with idetical beefits. If you completed ectio G for MUTUAL CARE 3 or MUTUAL CARE 5 KIP ectio H ad cotiue to ectio I. MA5933-11 ubmit to LTC ervice Office 8

If MUTUAL CARE 3 or MUTUAL CARE 5 was selected KIP ectio H. ectio H MUTUAL CARE MY WAY If you are customizig your pla COMPLETE this ectio H. Applicat A Applicat B (If selectig pouse hared Care Beefit, beefits must be idetical to Applicat A) 1 Maximum Mothly Beefit (MMB) (must eter): 1 Maximum Mothly Beefit (MMB) (must eter): $, per moth ($1,500-$15,000 i $500 icremets) 2 Maximum Lifetime Beefit = umber of moths selected x MMB (must check oe): 2 Year (24 moths) 3 Year (36 moths) 4 Year (48 moths) 5 Year (60 moths) 6 Year (72 moths) 8 Year (96 moths) Lifetime 3 Assisted Livig Facility Beefit as a Percetage of the Maximum Mothly Beefit (must check oe): $, per moth ($1,500-$15,000 i $500 icremets) 2 Maximum Lifetime Beefit = umber of moths selected x MMB (must check oe): 2 Year (24 moths) 3 Year (36 moths) 4 Year (48 moths) 5 Year (60 moths) 6 Year (72 moths) 8 Year (96 moths) Lifetime 3 Assisted Livig Facility Beefit as a Percetage of the Maximum Mothly Beefit (must check oe): Up to: Up to: 4 Home Health Care Beefit as a Percetage of the Maximum Mothly Beefit (must check oe): 4 Home Health Care Beefit as a Percetage of the Maximum Mothly Beefit (must check oe): Up to: Up to: 5 Cash Beefit 35% of Home Health Care Beefit 5 Cash Beefit 35% of Home Health Care Beefit (automatically icluded) (automatically icluded) 6 Caledar ay Elimiatio Period (must check oe): 6 Caledar ay Elimiatio Period (must check oe): 0 ay 30 ay 60 ay 90 ay 180 ay 365 ay 7 Iflatio Protectio: 7 Iflatio Protectio: (must check YE or NO ): YE, I am selectig the 5% Compoud Iflatio Protectio (Lifetime) NO, 5% Compoud Iflatio Protectio (Lifetime) is NOT desired: I have reviewed the Outlie of Coverage ad the graphs that compare the beefits ad premiums of this policy with ad without the pecifically, I have reviewed the optio for Compoud If you selected NO to the 5% Compoud (Lifetime), check oe Iflatio Optio below: with Future Purchase Optio 0 ay 30 ay 60 ay 90 ay 180 ay 365 ay (must check YE or NO ): YE, I am selectig the 5% Compoud Iflatio Protectio (Lifetime) NO, 5% Compoud Iflatio Protectio (Lifetime) is NOT desired: I have reviewed the Outlie of Coverage ad the graphs that compare the beefits ad premiums of this policy with ad without the pecifically, I have reviewed the optio for Compoud If you selected NO to the 5% Compoud (Lifetime), check oe Iflatio Optio below: with Future Purchase Optio MA5933-11 ubmit to LTC ervice Office 9

ectio H Applicat A 8 Noforfeiture Beefit horteed Beefit Period (must check YE or NO ): YE NO, Noforfeiture Beefit horteed Beefit Period optio is NOT desired: I have reviewed the Outlie of Coverage ad compared the beefits ad premiums of this policy with ad without the Noforfeiture Optio(s) that have bee made available ad I reject the Noforfeiture Beefit horteed Beefit Period optio that is available. MUTUAL CARE MY WAY (cotiued) Applicat B 8 Noforfeiture Beefit horteed Beefit Period (must check YE or NO ): OPTIONAL BENEFIT FOR MUTUAL CARE MY WAY YE NO, Noforfeiture Beefit horteed Beefit Period optio is NOT desired: I have reviewed the Outlie of Coverage ad compared the beefits ad premiums of this policy with ad without the Noforfeiture Optio(s) that have bee made available ad I reject the Noforfeiture Beefit horteed Beefit Period optio that is available. 9 Waiver of Elimiatio Period for Home Health Care Beefit 9 Waiver of Elimiatio Period for Home Health Care Beefit 10 pousal Beefits: 10 The pouse Waiver of Premium, pouse urvivorship Beefit ad pouse hared Care Beefit are oly available whe both pouses or omestic Parters apply at the same time ad both policies are issued. pouse Waiver of Premium pouse urvivorship Beefit pouse hared Care Beefit The pouse hared Care Beefit is oly available whe both policies are issued with idetical beefits. 11 pouse ecurity Beefit 11 Not available for issue ages 70 ad older, with pousal Beefits or if pouse or omestic Parter is applyig for this coverage. pouse s or omestic Parter s Name 12 Restoratio of Beefits 12 Restoratio of Beefits Not available with Lifetime Beefits. Not available with Lifetime Beefits. 13 Additioal Beefit for Ijury 13 Additioal Beefit for Ijury 14 Retur of Premium at eath Beefit: 14 Retur of Premium at eath Beefit: Retur of Premium (Less Claims Paid) If eath Occurs Before Age 65 OR Retur of Premium at eath (Less Claims Paid) OR Full Retur of Premium at eath Retur of Premium (Less Claims Paid) If eath Occurs Before Age 65 OR Retur of Premium at eath (Less Claims Paid) OR Full Retur of Premium at eath Cotiue to ectio I. MA5933-11 ubmit to LTC ervice Office 10

ectio I Applicat A PREMIUM INFORMATION Applicat B 1 Premium Optios (must check oe): 1 Premium Optios (must check oe): Lifetime igle Premium 10-Year Pay 20-Year Pay To-Age-65 Lifetime 2 Premium Amout: 2 Premium Amout: Modal Premium: $ igle Premium 10-Year Pay 20-Year Pay To-Age-65 Modal Premium: $ Premium Collected: $ Two Moths Miimum Premium Collected: $ Two Moths Miimum 3 Recurrig Premium Mode (check oe uless igle Premium): 3 Recurrig Premium Mode (check oe uless igle Premium): Mothly Automatic Checkig Accout (.09) eductio pecify the date premiums will be withdraw (1st through the 28th of the moth): Mothly Automatic Checkig Accout (.09) eductio pecify the date premiums will be withdraw (1st through the 28th of the moth): X Bak Name Routig Number Accout Number (Or iclude a voided check.) Bak Name Routig Number Accout Number (Or iclude a voided check.) Authorizatio to Withdraw Fuds by Mutual of Omaha Isurace Compay I authorize Mutual of Omaha Isurace Compay (Mutual of Omaha) to withdraw fuds from my accout for my iitial ad/or reewal premiums ad uderstad that the amouts may differ. I also authorize Mutual of Omaha to collect ay premium(s) due by bak draft withdrawal. Premium shortages may result from a variety of causes, icludig uderwritig adjustmets. I authorize you, my fiacial istitutio, to pay from my accout ay checks, drafts or preauthorized electroic fud trasfers from my accout to Mutual of Omaha. Your rights with each charge will be the same as if persoally paid by me. This authorizatio will be effective util I give you at least three busiess days otice to cacel it. If otice is give verbally, you may require writte cofirmatio from me withi 14 days after my verbal otice. X igature of Applicat A ate igature of Applicat B ate irect Bill: Quarterly (.26) emiaual (.51) Aual (1.0) Billig Address for Premium Notices (if differet from page 1): Name treet Address, Apartmet Number City, tate, ZIP Code irect Bill: Quarterly (.26) emiaual (.51) Aual (1.0) Billig Address for Premium Notices (if differet from page 1): Name treet Address, Apartmet Number City, tate, ZIP Code 4 elect Effective ate: 4 elect Effective ate: MA5933-11 ate of Applicatio ate Policy is Issued For Replacemets Oly, Requested Effective ate of Coverage (up to 60 days from applicatio date) ubmit to LTC ervice Office 11 ate of Applicatio ate Policy is Issued For Replacemets Oly, Requested Effective ate of Coverage (up to 60 days from applicatio date)

ectio J NOTICE BEFORE LAPE OR TERMINATION Please check the applicable box ad complete the requested iformatio. You may wat to cosider desigatig someoe other tha a pouse or omestic Parter. Applicat A Applicat B I wish to desigate a additioal perso to receive otice of lapse or termiatio of the policy due to opaymet of premium. I wish to desigate a additioal perso to receive otice of lapse or termiatio of the policy due to opaymet of premium. (If ifferet tha Applicat A) Name (Prit full ame of other perso to receive otice of lapse or termiatio) treet Address, Apartmet Number City, tate, ZIP Code Protectio agaist uiteded lapse. I uderstad that I have the right to desigate at least oe perso other tha myself to receive otice of lapse or termiatio of this log-term care isurace policy for opaymet of premium. I uderstad that otice will ot be give util thirty (30) days after a premium is due ad upaid. OR I elect NOT to desigate ay perso to receive such otice. Name (Prit full ame of other perso to receive otice of lapse or termiatio) treet Address, Apartmet Number City, tate, ZIP Code Protectio agaist uiteded lapse. I uderstad that I have the right to desigate at least oe perso other tha myself to receive otice of lapse or termiatio of this log-term care isurace policy for opaymet of premium. I uderstad that otice will ot be give util thirty (30) days after a premium is due ad upaid. OR I elect NOT to desigate ay perso to receive such otice. MA5933-11 ubmit to LTC ervice Office 12

ectio K AGREEMENT AN ACKNOWLEGEMENT 1. The udersiged applicat agrees that (a) all aswers i this applicatio are true ad complete ad Mutual of Omaha Isurace Compay will rely o these aswers to determie isurability, ad (b) icorrect or misleadig aswers may void this applicatio ad ay policy issued from its effective date. 2. Applicat ackowledges that Mutual of Omaha Isurace Compay may require: a Attedig Physicia s tatemet, medical records, a uderwritig assessmet, a medical examiatio, or other iformatio. 3. Applicat agrees that Mutual of Omaha Isurace Compay will ot issue a policy as a result of this applicatio uless (a) the isurace applicat completes all medical examiatios ad tests required by Mutual of Omaha Isurace Compay, (b) Mutual of Omaha Isurace Compay receives ay additioal iformatio requested for uderwritig (such as Persoal Worksheet, Persoal Health Iterview, or Attedig Physicia s tatemet), ad (c) the isurace applicat is, as of the policy applicatio date, determied to be eligible for the exact isurace coverage applied for, or the isurace applicat has subsequetly accepted a offer by Mutual of Omaha Isurace Compay for coverage other tha as applied for, accordig to the uderwritig stadards of Mutual of Omaha Isurace Compay the i force. 4. Applicat agrees that there is o temporary or iterim isurace prior to policy issuace. If the applicat has made a advace premium paymet, applicat agrees to the terms ad coditios of the Coditioal Receipt. Applicat agrees that completig this applicatio or makig a advace premium paymet is ot a guaratee that this applicatio will be approved. If approved, the issued policy will idicate its effective date. Applicat ackowledges that if his or her applicatio is declied, the log-term care coverage applied for will ot become effective ad ay advace premium paymet submitted with the applicatio will be refuded to applicat, without iterest. 5. Applicat ackowledges that o Producer ca (a) waive or chage ay receipt or policy provisio, or (b) agree to issue a policy. 6. Applicat ackowledges receipt of a Outlie of Coverage, hopper s Guide to Log-Term Care Isurace, Potetial Rate Icrease isclosure Form ad, if applicable, Guide to Health Isurace for People with Medicare. Fraud Warig: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio or coceals, for the purpose of misleadig, iformatio cocerig ay fact material thereto commits a fraudulet isurace act, which is a crime ad subjects such perso to crimial ad civil pealties. Cautio: If your aswers o this applicatio are icorrect or utrue, Mutual of Omaha Isurace Compay has the right to dey beefits or rescid your policy. I have read ad uderstad this Agreemets ad Ackowledgemets ectio, icludig the Fraud Warig ad I approve all my aswers as recorded i this applicatio. iged at iged at City tate City tate X X igature of Applicat A ate igature of Applicat B ate I/We, the Producer(s) certify that each questio was asked exactly as writte ad I/we have recorded the aswers provided by the Applicat(s) completely ad accurately. I/We also agree that my/our aswers i this applicatio are true ad complete. Yes No (If No, please explai) X igature of Licesed Producer(s) MA5933-11 ubmit to LTC ervice Office 13

Appedix 1 AUTHORIZATION TO ICLOE PERONAL INFORMATION I authorize physicias, medical or detal practitioers, hospitals, cliics, pharmacies, pharmacy beefit maagers, other medical care facilities, health maiteace orgaizatios, MIB (Medical Iformatio Bureau), isurers, employers, cosumer reportig agecies ad ay other orgaizatio, istitutio, or perso that has records or kowledge of me or my health to release persoal iformatio about me to Mutual of Omaha Isurace Compay or its affiliated compaies (Mutual). Persoal iformatio icludes my health iformatio such as medical history, metal or physical coditio, prescriptio drug records, drug or alcohol use ad other iformatio such as fiaces, occupatio, geeral reputatio ad isurace claims iformatio. The persoal iformatio may iclude my etire medical record. The Persoal iformatio will be used to determie my eligibility for isurace or to resolve or cotest ay issues of icomplete, icorrect or misrepreseted iformatio o the applicatio that may arise durig the processig of my applicatio or i coectio with a claim. I also authorize Mutual to disclose my persoal iformatio to the MIB. I uderstad that my persoal iformatio received by the MIB may be disclosed, upo request, to aother member compay with whom I apply for life or health isurace or to whom I may submit a claim for beefits. If the perso or etity to whom iformatio is disclosed is ot a health care provider or health pla subject to federal privacy regulatios, the iformatio may be redisclosed without the protectio of the federal privacy regulatios. I uderstad that I may refuse to sig this authorizatio. I realize if I refuse to sig, the isurace for which I am applyig will ot be issued. This authorizatio will expire 24 moths after the date siged. I may revoke this authorizatio at ay time by writte otice to ATTN: Idividual Uderwritig, Mutual of Omaha Isurace Compay, Mutual of Omaha Plaza, Omaha, NE 68175. This revocatio is limited to the extet that Mutual has take actio i reliace o the authorizatio or the law allows Mutual to cotest the issuace of the policy or a claim uder the policy. I uderstad that I will receive a copy of this authorizatio ad that a copy is as valid as the origial. Name(s) used for medical records (if differet tha the ame(s) below): Prited Name of Applicat A Birth tate ad Couty Prited Name of Applicat B Birth tate ad Couty X X igature of Applicat A ate igature of Applicat B ate MLU26722 THI AUTHORIZATION COMPLIE WITH HIPAA AN OTHER FEERAL AN TATE LAW ubmit to LTC ervice Office 14

Appedix 2 PROUCER TATEMENT 1. I/We certify that the Notice of Iformatio Practices ad Ivestigative Cosumer Reports Notice were give to the Applicat(s)... Yes No 2. I/We certify that each questio was asked exactly as writte ad that I/we recorded the aswers completely ad accurately i the presece of the Applicat(s)... (If No, explai) 3. This coverage is writte o myself (the Producer) ad/or my pouse or omestic Parter... 4. Please idicate the Uderwritig Risk classificatio quoted... Your quote will be oted, however, Uderwritig will determie the fial risk classificatio. We suggest quotig elect uless our Uderwritig Guide idicates the health coditio(s) warrats a substadard ratig. Class II cases should be discussed with a uderwriter prior to applicatio submissio. 5. To the best of my kowledge, replacemet of other isurace (check box) ivolved i this trasactio... If replacemet is ivolved, I/we shall comply with all state ad/or compay replacemet requiremets, icludig completig the applicable state required replacemet forms ad submittig copies of these forms with the applicatio. X igature of Producer (Aget of Record) ate X igature of Other Producer, if applicable ate Producer Iformatio (please prit clearly) Applicat A Preferred elect Class I Class II is is ot Applicat B Preferred elect Class I Class II is is ot For Mutual of Omaha Career Producers Oly: 01 Maager tamp M tamp Producer tamp For Brokerage Oly: Commissio Code 951300 (Examples: 8 8, A 2, etc.) ( Commissio code available from your marketig orgaizatio.) Producer s Name (Aget of Record) Producer s Idetificatio Number Other Producer s Name (If applicable, for Commissio plit) Producer s Idetificatio Number ocial ecurity Number Producer s Phoe Number ( ) Producer s E-mail Address ocial ecurity Number Producer s Phoe Number ( ) Producer s E-mail Address Whom should we cotact with questios regardig this applicatio if differet tha Producer listed above: Name Name of Office/Corporatio Phoe Number ( ) Fax Number ( ) E-mail Address ubmit to LTC ervice Office 15

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Appedix 3 Iitial Premium paid by check Applicat A ubmit to LTC ervice Office CONITIONAL RECEIPT Applicat B Received from Applicat A the sum of $ paid as the iitial premium with the attached Log-Term Care Isurace applicatio to Mutual of Omaha Isurace Compay. Received from Applicat B the sum of $ paid as the iitial premium with the attached Log-Term Care Isurace applicatio to Mutual of Omaha Isurace Compay. Total Premium $ (ALL CHECK FOR PREMIUM MUT BE MAE PAYABLE TO MUTUAL OF OMAHA INURANCE COMPANY ( MUTUAL OF OMAHA ). ONE CHECK I ACCEPTABLE FOR JOINT APPLICANT. O NOT MAKE CHECK PAYABLE TO THE PROUCER OR LEAVE THE PAYEE BLANK. O NOT COLLECT PREMIUM FOR INGLE PREMIUM CAE.) This receipt is give ad accepted with the uderstadig that the isurace applied for by each applicat will become effective o the date of the completed applicatio (uless a later date is selected by the applicat, i which case coverage will become effective o the date selected by the applicat) if all of the followig coditios have bee fully satisfied: 1. the isurace applicat completes all medical examiatios ad tests required by Mutual of Omaha Isurace Compay, 2. Mutual of Omaha Isurace Compay receives ay additioal iformatio requested for uderwritig (such as Persoal Worksheet, Persoal Health Iterview, or Attedig Physicia s tatemet), 3. the isurace applicat is, as of the policy applicatio date, determied to be eligible for the exact isurace coverage applied for, accordig to the uderwritig stadards of Mutual of Omaha Isurace Compay the i force, ad the policy is issued, ad 4. the isurace applicat has paid the first full premium accordig to the method of paymet selected i the applicatio. Mutual of Omaha Isurace Compay reserves the right to disapprove the applicatio by offerig to issue coverage other tha as applied for or by decliig to issue coverage. If applicable, Mutual of Omaha Isurace Compay will retur moies received with the applicatio if (a) the coverage, other tha applied for, is offered but ot accepted, or (b) if the coverage is declied. Ay delay i completio of the uderwritig process or refudig of moies shall ot be costrued as approval of the applicatio for coverage. This is ot a temporary isurace agreemet ad does ot create ay temporary or iterim isurace. iged at iged at City tate City tate X X igature of Applicat A ate igature of Applicat B ate X igature of Licesed Producer(s) ubmit to LTC ervice Office 16

Appedix 3 Iitial Premium paid by check Applicat A Leave this page with Applicat(s) CONITIONAL RECEIPT Applicat B Received from Applicat A the sum of $ paid as the iitial premium with the attached Log-Term Care Isurace applicatio to Mutual of Omaha Isurace Compay. Received from Applicat B the sum of $ paid as the iitial premium with the attached Log-Term Care Isurace applicatio to Mutual of Omaha Isurace Compay. Total Premium $ (ALL CHECK FOR PREMIUM MUT BE MAE PAYABLE TO MUTUAL OF OMAHA INURANCE COMPANY ( MUTUAL OF OMAHA ). ONE CHECK I ACCEPTABLE FOR JOINT APPLICANT. O NOT MAKE CHECK PAYABLE TO THE PROUCER OR LEAVE THE PAYEE BLANK. O NOT COLLECT PREMIUM FOR INGLE PREMIUM CAE.) This receipt is give ad accepted with the uderstadig that the isurace applied for by each applicat will become effective o the date of the completed applicatio (uless a later date is selected by the applicat, i which case coverage will become effective o the date selected by the applicat) if all of the followig coditios have bee fully satisfied: 1. the isurace applicat completes all medical examiatios ad tests required by Mutual of Omaha Isurace Compay, 2. Mutual of Omaha Isurace Compay receives ay additioal iformatio requested for uderwritig (such as Persoal Worksheet, Persoal Health Iterview, or Attedig Physicia s tatemet), 3. the isurace applicat is, as of the policy applicatio date, determied to be eligible for the exact isurace coverage applied for, accordig to the uderwritig stadards of Mutual of Omaha Isurace Compay the i force, ad the policy is issued, ad 4. the isurace applicat has paid the first full premium accordig to the method of paymet selected i the applicatio. Mutual of Omaha Isurace Compay reserves the right to disapprove the applicatio by offerig to issue coverage other tha as applied for or by decliig to issue coverage. If applicable, Mutual of Omaha Isurace Compay will retur moies received with the applicatio if (a) the coverage, other tha applied for, is offered but ot accepted, or (b) if the coverage is declied. Ay delay i completio of the uderwritig process or refudig of moies shall ot be costrued as approval of the applicatio for coverage. This is ot a temporary isurace agreemet ad does ot create ay temporary or iterim isurace. iged at iged at City tate City tate X X igature of Applicat A ate igature of Applicat B ate X igature of Licesed Producer(s) Leave this page with Applicat(s) 17

Appedix 4 MIB GROUP, INC. PRE-NOTICE Iformatio regardig your isurability will be treated as cofidetial. Mutual of Omaha Isurace Compay, or its reisurers may, however, make a brief report thereo to MIB, a ot-for-profit membership orgaizatio of isurace compaies, which operates a iformatio exchage o behalf of its members. If you apply to aother MIB Member compay for life or health isurace coverage, or a claim for beefits is submitted to such a compay, MIB, upo request, will supply such compay with the iformatio i its file. Upo receipt of a request from you, MIB will arrage disclosure of ay iformatio it may have i your file. Please cotact MIB at 866-692-6901 (TTY 866-346-3642). If you questio the accuracy of iformatio i MIB s file, you may cotact MIB ad seek a correctio i accordace with the procedures set forth i the federal Fair Credit Reportig Act. The address of MIB s iformatio is: 50 Braitree Hill, uite 400, Braitree, MA 02184-8734. Mutual of Omaha Isurace Compay, or its reisurers, may also release iformatio i its file to other isurace compaies to whom you may apply for life or health isurace, or to whom a claim for beefits may be submitted. Iformatio for cosumers about MIB may be obtaied o its website at www.mib.com. Appedix 5 COMPANY NOTICE OF INFORMATION PRACTICE I the course of properly uderwritig ad admiisterig your isurace coverage, we will rely heavily o iformatio provided by you. We may also collect iformatio from others, such as medical professioals who have treated you, hospitals, other isurace compaies, ad cosumer reportig agecies. I certai circumstaces, ad i compliace with applicable law, we or our reisurers may also release your persoal or privileged iformatio i our/their files, to third parties without your authorizatio. Upo request you have the right to be told about ad to see a copy of items of persoal iformatio about you which appear i our files, icludig iformatio cotaied i ivestigative cosumer reports. You also have the right to seek correctio of persoal iformatio you believe to be iaccurate. I compliace with applicable law, we or our reisurers may also release iformatio i our/their files, icludig iformatio i a applicatio, to other isurace compaies to which you apply for life or health isurace or to which a claim is submitted. o that there will be o questio that the isurace beefits will be payable at the time a claim is made, we urge you to review your applicatio carefully to be sure the aswers are correct ad complete. THE ABOVE I A GENERAL ECRIPTION OF OUR INFORMATION PRACTICE. IF YOU WOUL LIKE TO RECEIVE A MORE ETAILE EXPLANATION OF THEE PRACTICE, PLEAE EN YOUR REQUET TO: MUTUAL OF OMAHA INURANCE COMPANY, LONG-TERM CARE ERVICE OFFICE, P.O. BOX 64901, T. PAUL, MN 55164-0901. Appedix 6 INVETIGATIVE CONUMER REPORT NOTICE Mutual of Omaha Isurace Compay ( we ) may request that a ivestigative cosumer report be prepared, whereby iformatio about you is obtaied through persoal iterviews with your eighbors, frieds, associates, acquaitaces or others who may have kowledge relatig to your character, geeral reputatio, persoal characteristics, or mode of livig. Upo request, we will iform you whether a ivestigative cosumer report was doe, ad the ature ad scope of the ivestigatio. You may request to be iterviewed i coectio with the preparatio of a ivestigative cosumer report. You also have the right, upo request, to receive a copy of the ivestigative cosumer report from the cosumer reportig agecy that prepared it. We will provide you the ame, address ad telephoe umber of the cosumer reportig agecy so that you may request a copy of ay such report directly from the agecy. You may questio the accuracy or seek correctio of iformatio cotaied i such report. Leave this page with Applicat(s) 18

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Log-Term Care Isurace Notice to Applicat Regardig Replacemet of Idividual Accidet ad ickess or Log-Term Care Isurace Mutual of Omaha Isurace Compay Mutual of Omaha Plaza Omaha, Nebraska 68175 ave this otice! It may be importat to you i the future. Accordig to your applicatio, you ited to lapse or otherwise termiate existig accidet ad sickess or log-term care isurace ad replace it with a idividual log-term care policy to be issued by Mutual of Omaha Isurace Compay. Your ew policy provides 30 days withi which you may decide, without cost, whether you desire to keep the policy. For your ow iformatio ad protectio, you should be aware of ad seriously cosider certai factors which may affect the isurace protectio available to you uder the ew policy. You should review this ew coverage carefully, comparig it with all accidet ad sickess or log-term care isurace coverage you ow have, ad termiate your preset policy oly if, after due cosideratio, you fid that purchase of this log-term care coverage is a wise decisio. tatemet to Applicat by Producer I have reviewed your curret medical or health isurace coverage. I believe the replacemet of isurace ivolved i this trasactio materially improves your positio. My coclusio has take ito accout the followig cosideratios, which I call to your attetio. 1. Health coditios which you may presetly have (preexistig coditios) may ot be immediately or fully covered uder the ew policy. This could result i deial or delay i paymet of beefits uder the ew policy, whereas a similar claim might have bee payable uder your preset policy. 2. tate law provides that your replacemet policy or certificate may ot cotai ew preexistig coditios, waitig periods, elimiatio periods or probatioary periods. The isurer will waive ay time periods applicable to preexistig coditios, waitig periods, elimiatio periods or probatioary periods i the ew policy for similar beefits to the extet such time was spet uder the origial policy. 3. If you are replacig existig log-term care isurace coverage, you may wish to secure the advice of your preset isurer or its producer regardig the proposed replacemet of your preset policy. This is ot oly your right, but it is also i your best iterest to make sure you uderstad all the relevat factors ivolved i replacig your preset coverage. 4. If, after due cosideratio, you still wish to termiate your preset policy ad replace it with ew coverage, be certai to truthfully ad completely aswer all questios o the applicatio cocerig your medical/ health history. Failure to iclude all material medical iformatio o a applicatio may provide a basis for the Compay to dey ay future claims ad to refud your premium as though your policy had ever bee i force. After the applicatio has bee completed ad before you sig it, reread it carefully to be certai that all iformatio has bee properly recorded. X igature of Producer Prited Name ad Address of Producer The above Notice to Applicat was delivered to me o: X igature of Applicat A X igature of Applicat B ate ate M26680 ubmit to LTC ervice Office

Log-Term Care Isurace Notice to Applicat Regardig Replacemet of Idividual Accidet ad ickess or Log-Term Care Isurace Mutual of Omaha Isurace Compay Mutual of Omaha Plaza Omaha, Nebraska 68175 ave this otice! It may be importat to you i the future. Accordig to your applicatio, you ited to lapse or otherwise termiate existig accidet ad sickess or log-term care isurace ad replace it with a idividual log-term care policy to be issued by Mutual of Omaha Isurace Compay. Your ew policy provides 30 days withi which you may decide, without cost, whether you desire to keep the policy. For your ow iformatio ad protectio, you should be aware of ad seriously cosider certai factors which may affect the isurace protectio available to you uder the ew policy. You should review this ew coverage carefully, comparig it with all accidet ad sickess or log-term care isurace coverage you ow have, ad termiate your preset policy oly if, after due cosideratio, you fid that purchase of this log-term care coverage is a wise decisio. tatemet to Applicat by Producer I have reviewed your curret medical or health isurace coverage. I believe the replacemet of isurace ivolved i this trasactio materially improves your positio. My coclusio has take ito accout the followig cosideratios, which I call to your attetio. 1. Health coditios which you may presetly have (preexistig coditios) may ot be immediately or fully covered uder the ew policy. This could result i deial or delay i paymet of beefits uder the ew policy, whereas a similar claim might have bee payable uder your preset policy. 2. tate law provides that your replacemet policy or certificate may ot cotai ew preexistig coditios, waitig periods, elimiatio periods or probatioary periods. The isurer will waive ay time periods applicable to preexistig coditios, waitig periods, elimiatio periods or probatioary periods i the ew policy for similar beefits to the extet such time was spet uder the origial policy. 3. If you are replacig existig log-term care isurace coverage, you may wish to secure the advice of your preset isurer or its producer regardig the proposed replacemet of your preset policy. This is ot oly your right, but it is also i your best iterest to make sure you uderstad all the relevat factors ivolved i replacig your preset coverage. 4. If, after due cosideratio, you still wish to termiate your preset policy ad replace it with ew coverage, be certai to truthfully ad completely aswer all questios o the applicatio cocerig your medical/ health history. Failure to iclude all material medical iformatio o a applicatio may provide a basis for the Compay to dey ay future claims ad to refud your premium as though your policy had ever bee i force. After the applicatio has bee completed ad before you sig it, reread it carefully to be certai that all iformatio has bee properly recorded. X igature of Producer Prited Name ad Address of Producer The above Notice to Applicat was delivered to me o: X igature of Applicat A X igature of Applicat B ate ate M26680 Leave this page with Applicat(s)

Log-Term Care Isurace Potetial Rate Icrease isclosure Form This is ot applicable to sigle premium. 1. Premium Rate: Premium rate that is applicable to you ad that will be i effect util a request is made ad approved for a icrease is: Applicat A $ Applicat B $ 2. The premium for this policy will be show o the schedule page of your policy. 3. Rate chedule Adjustmets: The premium rates for this policy may chage. Ay chage will be effective o the ext billig date after the compay has provided you at least 60 days writte otice before we chage premiums. 4. Potetial Rate Revisios: This policy is Guarateed Reewable. This meas that the rates for this product may be icreased i the future. Your rate ca NOT be icreased due to your icreasig age or decliig health, but your rates may go up based o the experiece of all policyholders with a policy similar to yours. If you receive a premium rate or premium rate schedule icrease i the future, you will be otified of the ew premium amout ad you will be able to exercise at least oe of the followig optios: Pay the icreased premium ad cotiue your policy i force as is. Reduce your policy beefits to a level such that your premiums will ot icrease. (ubject to state law miimum stadards.) Exercise your oforfeiture optio if purchased. (This optio is available for purchase for a additioal premium.) Exercise your cotiget oforfeiture rights.* (This optio may be available if you do ot purchase a separate oforfeiture optio.) M26682 Leave this page with Applicat(s) *Cotiget Noforfeiture If the premium rate for your policy goes up i the future ad you did t buy a oforfeiture optio, you may be eligible for cotiget oforfeiture. Here s how to tell if you are eligible: You will keep some log-term care isurace coverage, if: Your premium after the icrease exceeds your origial premium by the percetage show (or more) i the followig table; ad You lapse (ot pay more premiums) withi 120 days of the icrease. The amout of coverage (i.e., ew lifetime maximum beefit amout) you will keep will equal the greater of the total amout of premiums you ve paid sice your policy was first issued or the maximum mothly beefit. If you have already received beefits uder the policy, so that the remaiig lifetime maximum beefit amout is less tha the total amout of premiums you ve paid, the amout of coverage will be that remaiig amout. Except for this reduced lifetime maximum beefit amout, all other policy beefits will remai at the levels attaied at the time of the lapse ad will ot icrease thereafter. hould you choose this Cotiget Noforfeiture optio, your policy, with this reduced maximum beefit amout, will be cosidered paid-up with o further premiums due. Example: You bought the policy at age 65 ad paid the $1,000 aual premium for 10 years, so you have paid a total of $10,000 i premium. I the eleveth year, you receive a rate icrease of 50%, or $500 for a ew aual premium of $1,500, ad you decide to lapse the policy (ot pay ay more premiums). Your paid-up policy beefits are $10,000 (provided you have at least $10,000 of beefits remaiig uder your policy).

Cotiget Noforfeiture Cumulative Premium Icrease over Iitial Premium That Qualifies for Cotiget Noforfeiture (Percetage icrease is cumulative from date of origial issue. It does NOT represet a oe time icrease.) Issue % Icrease Over Issue % Icrease Over Issue % Icrease Over Age Iitial Premium Age Iitial Premium Age Iitial Premium 29 ad uder 200% 66 48% 79 22% 30-34 190% 67 46% 80 20% 35-39 170% 68 44% 81 19% 40-44 150% 69 42% 82 18% 45-49 130% 70 40% 83 17% 50-54 110% 71 38% 84 16% 55-59 90% 72 36% 85 15% 60 70% 73 34% 86 14% 61 66% 74 32% 87 13% 62 62% 75 30% 88 12% 63 58% 76 28% 89 11% 64 54% 77 26% 90 ad over 10% 65 50% 78 24% I additio to the cotiget oforfeiture beefits described above, the followig reduced paid-up cotiget oforfeiture beefit is a optio i all policies that have a fixed or limited premium paymet period, eve if you selected a oforfeiture beefit whe you bought your policy. If both the reduced paid up beefit AN the cotiget beefit described above are triggered by the same rate icrease, you ca choose either of the two beefits. You are eligible for the reduced paid up cotiget oforfeiture beefit whe all three coditios show below are met: 1. The premium you are required to pay after the icrease exceeds your origial premium by the same percetage or more show i the chart below: Triggers of ubstatial Premium Icrease Issue % Icrease Over Age Iitial Premium Uder 65 50% 65-80 30% Over 80 10% 2. You stop payig your premiums withi 120 days of whe the premium icrease took effect; AN 3. The ratio of the umber of moths you already paid premiums is 40% or more tha the umber of moths you origially agreed to pay. If you exercise this optio your coverage will be coverted to reduced paid-up status. That meas there will be o additioal premiums required. Your beefits will chage i the followig ways: a. The total lifetime amout of beefits your reduced paid up policy will provide ca be determied by multiplyig 90% of the lifetime beefit amout at the time the policy becomes paid up by the ratio of the umber of moths you already paid premiums to the umber of moths you agreed to pay them. b. The maximum mothly beefit amouts you purchased will also be adjusted by the same ratio. If you purchased lifetime beefits, oly the maximum mothly beefit amouts you purchased will be adjusted by the applicable ratio. Example: You bought the policy at age 65 with a aual premium payable for 10 years. I the sixth year, you receive a rate icrease of 35% ad you decide to stop payig premiums. Because you have already paid 50% of your total premium paymets ad that is more tha the 40% ratio, your paid-up policy beefits are.45 (.90 times.50) times the total beefit amout that was i effect whe you stopped payig your premiums. If you purchased iflatio protectio, it will ot cotiue to apply to the beefits i the reduced paid-up policy. M26682 Leave this page with Applicat(s)

Thigs You hould Kow Before You Buy Log-Term Care Isurace Log-Term Care Isurace A log-term care isurace policy may pay most of the costs for your care i a ursig home. May policies also pay for care at home or other commuity settigs. ice policies ca vary i coverage, you should read this policy ad make sure you uderstad what it covers before you buy it. You should ot buy this isurace policy uless you ca afford to pay the premiums every year. Remember that the compay ca icrease premiums i the future. This is ot applicable to sigle premium. The persoal worksheet icludes questios desiged to help you ad the compay determie whether this policy is suitable for your eeds. Medicare Medicare does ot pay for most log-term care. Medicaid Medicaid will geerally pay for log-term care if you have very little icome ad few assets. You probably should ot buy this policy if you are ow eligible for Medicaid. May people become eligible for Medicaid after they have used up their ow fiacial resources by payig for log-term care services. Whe Medicaid pays your spouse s ursig home bills, you are allowed to keep your house ad furiture, a livig allowace, ad some of your joit assets. Your choice of log-term care services may be limited if you are receivig Medicaid. To lear more about Medicaid, cotact your local or state Medicaid agecy. M26683 Leave this page with Applicat(s) hopper s Guide Make sure the isurace compay or producer gives you a copy of a book called the Natioal Associatio of Isurace Commissioers hopper s Guide to Log-Term Care Isurace. Read it carefully. If you have decided to apply for log-term care isurace, you have the right to retur the policy withi 30 days ad get back ay premium you have paid if you are dissatisfied for ay reaso or choose ot to purchase the policy. Couselig Free couselig ad additioal iformatio about log-term care isurace are available through your state s isurace couselig program. Cotact your state isurace departmet or departmet o agig for more iformatio about the seior health isurace couselig program i your state. Facilities ome log-term care isurace cotracts provide for beefit paymets i certai facilities oly if they are licesed or certified, such as i assisted livig ceters. However, ot all states regulate these facilities i the same way. Also, may people move to a differet state from where they purchased their log-term care isurace policy. Read the policy carefully to determie what types of facilities qualify for beefit paymets, ad to determie that paymet for a covered service will be made if you move to a state that has a differet licesig scheme for facilities tha the oe i which you purchased the policy.

eior Health Couselig Notice Please be advised that seior health isurace couselig is available at: eior Health Isurace Program (HIP) 320 West Washigto treet prigfield, IL 62767 1-800-548-9034 M20779

Foreig Natioal ad Foreig Travel Questioaire To be completed by Proposed Isured(s) or Policyower(s) Please attach a additioal sheet of paper if ecessary 1 Are you a U.. citize?...................................................................... Yes No (If Yes, proceed to Questio 2.) (a) Are you a Permaet Residet (holder of a Permaet Residet Card)?............................ Yes No (1) If "Yes," please list your Permaet Residet Card Number: (2) If "No," please list the type of visa you hold: How log have you lived i the Uited tates? (b) Please provide your full ame as stated o the Permaet Residet Card or Visa: (c) ate of issue o your Permaet Residet Card or Visa: (d) ate of expiratio o your Permaet Residet Card: (e) Coutry of Birth: _ (f) o you ow a home i the Uited tates?................................................... Yes No If Yes, please provide the address: (g) o you ow a home i a foreig coutry?................................................... Yes No If Yes, please provide the address: (h) If married, does your family live with you i the Uited tates?.................................. Yes No 2 Are you employed i the Uited tates?........................................................ Yes No (a) If "Yes," please provide the ame ad address of your employer ad describe the duties you perform. (b) If "No," please provide source(s) of icome while livig i the Uited tates. 3 o you pla to travel outside of the Uited tates i the ext two years?.............................. Yes No (If "Yes," please aswer the followig questios below:) (a) Where do you pla to travel? (b) What is the purpose of travel? Busiess _Pleasure (c) How ofte? (d) Average period of time for each trip: (e) What was the date of your last trip? I hereby represet that all the statemets ad aswers to the above questios are true ad complete to the best of my kowledge ad belief, ad will be relied upo to determie my eligibility for isurace. I also uderstad that this siged form will be used durig the uderwritig process ad ay misstatemets may affect my ability to obtai coverage. _ igature(s) of Proposed Isured(s) _ igature(s) of Policyower(s) ate ate Producer tatemet: I the presece of the isured(s) I have asked each questio as writte ad have recorded the aswers completely ad accurately. If questio 1 was aswered "No," I have see the proposed isured(s) or policyower(s) Permaet Residet Card.......................................................... Yes No If "No," please provide explaatio. igature(s) of Producer(s) ate L5719_0107

Mutual of Omaha Isurace Compay Mutual Care Plus Log-Term Care Isurace AGENT ad UNERWRITING GUIE Mutual Care 3 & 5 Mutual Care My Way M26795 For producer use oly. Not for use with the geeral public.

Table of Cotets Cotact Iformatio... ectio 1 Mutual Care Plus... ectio 2 Built-i ad Optioal Beefits Beefit escriptios Additioal Policy etails How to Geerate a Quote Admiistrative Hadlig... ectio 3 Geeral Uderwritig Guidelies... ectio 4 Policy Uderwritig Applicatio Completio Uderwritig Requiremets Uderwritig Philosophy Rate Classes Preferred Criteria Build Chart Health-Related Uderwritig Guidelies... ectio 5 Uisurable Health Coditios ome Medicatios Associated with Uisurable Health Coditios Uisurable Health Combiatios Medical Impairmets tate iffereces Matrix... ectio 6 M26795_0609

Cotact Iformatio Mailig Addresses Geeral Mail Expedited Mail Log-Term Care ervice Office Log-Term Care ervice Office P.O. Box 64901 7805 Hudso Rd., uite 180 t. Paul, MN 55164-0901 Woodbury, MN 55125-1591 ectio 1 Premium ubmissio (other tha premium collected with the applicatio) Geeral Mail Expedited Mail Mutual of Omaha 1st Natioal Bak P.O. Box 30154 Att: Wholesaler LB#30154 Omaha, NE 68103-1252 1620 odge t. Omaha, NE 68197 LTC ervice Office Claims Phoe: 877-894-2478 Hours: 7 a.m. to 5 p.m. Cetral time Moday Friday Customer ervice Phoe: 877-894-2478 Hours: 7 a.m. to 5 p.m. Cetral time Moday Friday New Busiess ervice Policy Issue Billig ad Collectio Mutual of Omaha Licesig Phoe: 800-867-6873 Hours: 8 a.m. to 4:30 p.m. Cetral time Moday Friday Fax Numbers 888-539-4672 Applicatio Requiremets 800-921-9335 Medical Iformatio elivery Requiremets Policy Chage Requests Correspodece ales upport Phoe: 877-617-5589 or 800-693-6083 Hours: 8 a.m. to 4:30 p.m. Cetral time Moday Friday E-mail: sales.support@mutualofomaha.com Appoitmets Cotractig Licesig Proposals ales/product upport Uderwritig Phoe: 800-551-2059 Hours: 8 a.m. to 4:30 p.m. Cetral time Moday Friday E-mail: ltcuderwritig@mutualofomaha.com Prequalificatio Risk electio To Iitiate the Persoal Health Iterview Phoe: 866-544-1617 1

2

Mutual Care Plus Mutual Care 3 Mutual Care 5 Mutual Care My Way Built-i ad Optioal Beefits The followig chart cotais the built-i ad optioal beefits of Mutual Care 3, Mutual Care 5 ad Mutual Care My Way. Beefits may vary by state. Please see the tate iffereces Matrix (sectio 6). Mutual Care 3 Mutual Care 5 Mutual Care My Way Built-i Beefits Beefit Period 3 years 5 years 2 years (24 moths) 3 years (36 moths) 4 years (48 moths) 5 years (60 moths) 6 years (72 moths) 8 years (96 moths) Lifetime Maximum Mothly Beefit $3,000 to $15,000 i $500 icremets $3,000 to $15,000 i $500 icremets $1,500 to $15,000 i $500 icremets ectio 2 Cash Beefit 35% of home health care maximum mothly beefit 35% of home health care maximum mothly beefit 35% of home health care maximum mothly beefit Elimiatio Period 90 caledar days 90 caledar days 0 caledar days 30 caledar days 60 caledar days 90 caledar days 180 caledar days 365 caledar days Iflatio Protectio 3% Compoud (lifetime) 5% Compoud (20-year) 5%, 4% or 3% Compoud (lifetime) 5% Compoud (20-year) 5% imple (lifetime) Mothly Beefit Optios (percetage of maximum mothly beefit) No Iflatio Protectio with Future Purchase Optio 100% 100% Home Health Care 100%, 75%, 50% Assisted Livig 100%, 75%, 50% Nursig Home 100% 3

pouse Beefits pouse hared Care pouse ecurity Beefit pouse Waiver of Premium pouse urvivorship No-forfeiture Optios Cotiget No-forfeiture No-forfeiture horteed Beefit Period Retur of Premium Optios Retur of Premium Less Claims Paid Retur of Premium Less Claims Paid if eath Occurs Before Age 65 Full Retur of Premium Other Optioal Beefits Waiver of Elimiatio Period for Home Health Care Restoratio of Beefits Additioal Beefit for Ijury 5-Year Rate Guaratee Mutual Care 3 Mutual Care 5 Mutual Care My Way Optioal Beefits Optioal Not available Not available Not available efault Optioal Not available Not available Not available Not available Not available Not available Not available Optioal Not available Not available Not available efault Optioal Not available Not available Not available Not available Not available Not available Not available Optioal Optioal Optioal Optioal efault Optioal Optioal Optioal Optioal Optioal Optioal Optioal Optioal 4

Beefit escriptios This sectio cotais a explaatio of the built-i ad optioal beefits of Mutual Care 3, Mutual Care 5 ad Mutual Care My Way. Additioal Beefit for Ijury Pays a additioal beefit if the isured sustais a ijury resultig i eed for log-term care services (home health care, assisted livig facility or ursig home). The ijury must be sustaied while the policy is i force ad the isured is ot chroically ill. The additioal beefit for ijury is payable ay moth the isured icurs eligible expeses i excess of the ursig home, assisted livig facility or home health care beefits paid that moth, up to the maximum mothly beefit of the policy. Available oly o Mutual Care My Way Not available for issue ages over 60 Cash Beefit Whe elected, pays a cash beefit (equal to 35 percet of the home health care maximum mothly beefit) i advace each moth. The elimiatio period does ot eed to be satisfied for the isured to receive the cash beefit. ectio 2 If we determie the isured is eligible for a cash beefit for less tha a etire moth, we will adjust the cash beefit for that moth. We will assume such a moth cosists of 30 days, regardless of the actual umber of days i the moth. If i ay moth, the isured receives a cash beefit i excess of the amout for which they are eligible, we will reduce ay future beefits paid uder the policy by the amout of the ueared cash beefit. Whe the isured is receivig a cash beefit, o other beefits are payable uder the policy. The isured may elect to discotiue the cash beefit by providig writte otice to us. After the cash beefit is discotiued, other eligible policy beefits may be payable o a reimbursemet basis. The isured may elect to receive the cash beefit oe moth ad reimbursemet the ext. We reserve the right to require a ew pla of care at least oce every 60 days whe the isured is receivig the cash beefit. Please ote, days i which the cash beefits are utilized do ot cout toward the elimiatio period for reimbursemet beefits. Elimiatio Period Oce the policy s elimiatio period has bee satisfied, the policy pays up to the maximum mothly beefit amout for covered log-term care services. No elimiatio period to satisfy whe the cash beefit is elected (if isured chages to reimbursemet beefits, elimiatio period must be satisfied) If isured is Class I or II risk, oly 90-, 180- ad 365-day elimiatio periods are available Five-Year Rate Guaratee Guaratees the iitial rate for a five-year period. Available oly o Mutual Care My Way Not available with igle Premium paymet optio Iflatio Protectio Automatically icrease the isured s curret maximum mothly beefit ad maximum lifetime beefit o each policy aiversary date to help keep pace with iflatio. Built-i Iflatio Protectio The followig iflatio protectio optios are built ito Mutual Care 3 ad 5 ad caot be removed or chaged: 3% Compoud (lifetime) Mutual Care 3 5% Compoud (20-year) Mutual Care 5 5

Optioal Iflatio Protectio Mutual Care My Way offers a variety of iflatio protectio optios: 5%, 4% or 3% Compoud (lifetime) 5% Compoud (20-year) 5% imple (lifetime) A iflatio protectio optio may be removed after issue with o refud of premium. The maximum mothly beefit ad remaiig maximum lifetime beefit will remai at the level to which they had bee icreased by this beefit as of the date the beefit is removed. The premium will be chaged to the appropriate premium amout for the icreased beefit amout provided, based o the age at issue. No Iflatio Protectio with Future Purchase Optio Also available o Mutual Care My Way. If o iflatio protectio is elected at the time of sale, the isured ca exercise the future purchase optio oe time withi a five-year period followig policy issue as log as he or she is ot chroically ill ad has ot bee o claim i the past two years. Caot be exercised if the isured is o Waiver of Premium Caot be added, removed or decreased after issue at the isured s request, except for the first 60 days followig policy iceptio (durig the first 60 days, the isured ca remove the Future Purchase Optio, but must select aother iflatio protectio optio) Whe the isured elects to exercise the Future Purchase Optio, he or she will be offered either a three percet compoud (lifetime) or five percet compoud (lifetime) iflatio protectio rider, which will be effective o the ext policy aiversary date. Oce this optio has bee exercised, o additioal icreases or decreases to the Future Purchase Optio rider will be allowed. Not available with ay other iflatio protectio optio Available oly with the Lifetime paymet optio Noforfeiture horteed Beefit Period As log as the policy has bee i force for a specified time, this optioal rider allows coverage to cotiue o a reduced basis i the evet the policy is termiated. If ot selected, Cotiget No-forfeiture is the default Not available with igle Premium paymet optio Restoratio of Beefits If beefits have bee paid uder the policy ad the isured o loger requires log-term care services for 180 cosecutive days, we will restore the maximum lifetime beefit to the amout that would have applied if o beefits had bee paid uder the policy (except for beefits paid for the spouse uder the pouse hared Beefit). This restoratio may occur oe time durig the term of the policy. Available oly o Mutual Care My Way Not available with Lifetime beefits Retur of Premium Optios Upo the death of the isured, the premium paid o the policy may be retured to the isured s heirs. The followig optios are available o Mutual Care My Way: Retur of Premium Less Claims Paid If the isured dies while the policy is i force, we will retur the total amout of premium paid for the policy, less the amout of claims paid uder the policy. Available oly o Mutual Care My Way Not available with pouse hared Care Not available for issue ages over 64 6

Retur of Premium Less Claims Paid if eath Occurs Before Age 65 If the isured dies while the policy is i force, but prior to the policy aiversary date coicidig with or ext followig his or her 65th birthday, we will retur the total amout of premium paid for the policy, less the amout of claims paid uder the policy. Available oly o Mutual Care My Way Not available for issue ages over 64 Full Retur of Premium If the isured dies while the policy is i force, we will retur the total amout of premium paid for the policy Available oly o Mutual Care My Way Not available with pouse hared Care Not available for issue ages over 64 pouse ecurity Beefit Pays a beefit equal to 60 percet of other policy beefits payable each moth (excludig the cash beefit, if ay). pouse security beefits will ot reduce the maximum lifetime beefit of the policy. Available oly o Mutual Care My Way Not available for Class I ad II risks Not available with other spouse beefits (pouse hared Care, pouse Waiver of Premium or pouse urvivorship) Not available with pouse or Two-Perso Household premium allowaces Not available for issue ages over 69 ectio 2 pouse hared Care Beefit Oce beefits have bee exhausted uder the isured s policy but the eed for log-term care services cotiues, the isured may access beefits uder his or her spouse s idetical policy util a miimum of 12 times the curretly mothly beefit remais. I additio, if oe spouse dies while both policies are i force, the survivig spouse will receive the deceased spouse s remaiig maximum lifetime beefit with o effect o the survivig spouse s premium. This optioal beefit is available oly whe both spouses or domestic parters apply at the same time ad are issued idetical coverage. Not available for Class II risks Not available for Class I risks with a maximum lifetime beefit greater tha 3 years Not available with the pouse ecurity Beefit Not available with Retur of Premium at eath Less Claims Paid or Full Retur of Premium Not available with Lifetime beefits Not available if uderwritig determies oe or both applicats pose a greater tha ormal risk of premature death Not available with Married or Two-Perso Household premium allowaces pouse urvivorship Beefit If the policy has bee i force for 10 years or more, o further premiums are due ad payable o the policy from ad after the date the spouse dies. Note: If premiums are icreased after policy issue do to a icrease or additio of coverage, the icreased premium must be i effect for 10 years or more before the icreased amout will be waived. Available oly o Mutual Care My Way Not available with pouse ecurity Beefit Not available with 10-Year, 20-Year, To-Age-65 or igle Premium paymet optios Not available with Married or Two-Perso Household premium allowaces Not available o Class I ad Class II risks 7

pouse Waiver of Premium We will waive the paymet of premium for the isured whe ad for as log as the premium for the spouse s policy is waived. Whe the waiver period uder the spouse s policy eds, premium paymets will resume for the isured s policy ad must be paid to keep the policy i force. Available oly o Mutual Care My Way Not available with pouse ecurity Beefit Not available with 10-Year, 20-Year, To-Age-65 or igle Premium paymet optios Not available with Married or Two-Perso Household premium allowaces Not available with Class I ad Class II risks Waiver of Elimiatio Period for Home Health Care No elimiatio period must be satisfied i order to receive home health care beefits uder the policy. Available oly o Mutual Care My Way Not available for Class I or II risks Additioal Policy etails The followig policy details apply to all Mutual Care Plus policies. Issue Ages Issue ages for all Mutual Care Plus policies are ages 18 to 79. Tax tatus All Mutual Care Plus policies are iteded to be tax-qualified. Premium Allowaces All Mutual Care Plus policies offer the followig premium allowaces: pouse 35 percet each if both the isured ad spouse or domestic parter purchase log-term care isurace from Mutual of Omaha Not available with pouse ecurity Beefit Preferred 15 percet for beig i good health Married 15 percet if the isured is married, but the spouse or domestic parter does ot purchase log-term care isurace from Mutual of Omaha Not available with pouse Waiver of Premium, pouse urvivorship or pouse hared Care beefits Two-Perso Household 10 percet each if both the isured ad aother adult livig i the same household for a cotiuous 12 moths (ot the isured s spouse or domestic parter) purchase log-term care isurace from Mutual of Omaha Not available with pouse Waiver of Premium, pouse urvivorship, pouse ecurity or pouse hared Care beefits Associatio Group 5 percet if the isured or a eligible member of the isured s family is a member of a qualifyig associatio group Not available with limited pay optios, except To-Age-65 Not available with Producer Allowace 8

Medicare upplemet 5 percet if the isured is a Mutual of Omaha, Uited of Omaha or Uited World Medicare supplemet policyholder Not available with Producer Allowace Producer 5 percet if coverage is writte o you ad/or your spouse or domestic parter Premium Paymet Optios The followig premium paymet optios are available o all Mutual Care Plus policies: Lifetime Premium paymets are level ad made over the life of the isured efault optio if o other premium optio is selected 10-Year Pay Premium paymets are made over a 10-year period Oly available at issue May be removed at the request of the isured. The premium removal will be based o the isured s origial age. No premium credit (refud or advace of the paid-to-date) will be give Not available with Class I or II risks Not available o Associatio/posored Group policies Not available with pouse Waiver of Premium or pouse urvivorship Not available with No Iflatio with Future Purchase Optio ectio 2 20-Year Pay Premium paymets are made over a 20-year period Oly available at issue May be removed at the request of the isured. The premium removal will be based o the isured s origial age. No premium credit (refud or advace of the paid-to-date) will be give Not available with Class I or II risks Not available o Associatio/posored Group policies Not available with pouse Waiver of Premium or pouse urvivorship Not available with No Iflatio with Future Purchase Optio To-Age-65 Premium paymets are made util the isured reaches age 65 Oly available at issue Maximum issue age is through age 54 May be removed at the request of the isured. The premium removal will be based o the isured s origial age. No premium credit (refud or advace of the paid-to-date) will be give Not available with Class I or II risks Not available with pouse Waiver of Premium or pouse urvivorship Not available with No Iflatio with Future Purchase Optio igle Premium A oe-time premium paymet is made Oly available at issue The policy will be cosidered paid up If selected, the Noforfeiture/horteed Beefit Period is ot available Not available with Class I or II risks Not available o Associatio/posored Group policies Not available with pouse Waiver of Premium or pouse urvivorship Not available with No Iflatio with Future Purchase Optio 9

How to Geerate a Quote Mutual Care 3 ad 5 Mutual Care 3 ad 5 are pre-packaged plas with limited optioal features, which makes them easy to quote. I most cases, all you eed is a rate chart ad the premium worksheet located i the Cosumer Guide (applicatio booklet). Mutual of Omaha Isurace Compay Mutual Care 3 Mutual Care 5 Log-Term Care Isurace Premium Worksheet 1 2 3 4 Applicat A Base Package Rate $ $ Optioal Beefits pouse hared Care Beefit x 1.16 $ $ (Policies must have idetical beefits) Applicat B Premium Allowaces (select all that apply*) Associatio Group 5% x 0.95 $ $ (Qualifyig associatio members) Medicare upplemet 5% x 0.95 $ $ (Mutual of Omaha Isurace Compay or a affiliate compay) pouse 35% x 0.65 $ $ (Policies issued o both spouses) Married 15% x 0.85 (Policy issued o oe spouse) Two-Perso Household 10% x 0.90 (Policies issued o two adults) * pouse, Married ad Two-Perso Household allowaces may ot be combied. NOTE: You also may qualify for a 15% Preferred premium allowace for beig i good health. The Preferred allowace, if applicable, will be applied followig completio of the uderwritig process. Estimated Total Premium** If paid aually x 1.00 $ $ If paid mothly x 0.09 $ $ (Miimum of two moths premium must be submitted with each applicatio) ** ue to the effects of roudig, rates calculated usig this worksheet may vary slightly from actual rates. Note: If you selected a maximum mothly beefit amout of $12,500 or more or additioal optios, icludig No-Forfeiture horteed Beefit Period or aother method of paymet, your Mutual of Omaha isurace aget will provide a illustratio showig your premium. 10

The followig umbers correspod with umbers o the premium worksheet: 1. Trasfer the appropriate base package rate from the rate chart (NOTE: Be sure to use the rate card with approved rates i your state) 2. Calculate the rate icludig the pouse hared Care Beefit optio, if selected (base rate times 1.16) 3. Calculate the rate icludig ay premium allowaces (rate from tep 2 times the appropriate factor) 4. Calculate the estimated total premium (rate from tep 3 times the appropriate factor) Please Note: ue to the effects of roudig, rates calculated usig the rate chart ad premium worksheet may vary slightly from actual rates computed usig illustratio software. Be sure to calculate rates i the order show o the premium worksheet to esure your calculatios are as close as possible to actual rates. Mior adjustmets, up or dow, may be required ad will be made by the home office. Illustratio software is required to geerate a quote if: The applicat is age 71 or older The Noforfeiture horteed Beefit Period optio is selected If a paymet method other tha aual or mothly is selected Ay amout quoted over $12,000 ectio 2 Mutual Care My Way Mutual Care My Way offers a variety of pla choices ad optioal beefits that allow you to customize a policy to meet your cliets uique eeds. I order to provide a accurate quote, the use of illustratio software is required. 11

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Admiistrative Hadlig owgrades/roppig Coverage rop: Iflatio Protectio ROP at eath <65 ROP at eath (less claims paid) Noforfeiture horteed Beefit Period pouse urvivorship pouse Waiver of Premium pouse ecurity Beefit Restoratio of Beefits pouse hared Care Beefit owgrades/reducig Coverage Reduce: Maximum Mothly Beefit; or Maximum Lifetime Beefit(s) Icrease: Elimiatio Period Chages to Premium Payig Period Covert from limited pay to lifetime ame policy umber Cotiuig beefits keep origial issue age Cotiuig beefits cotiue to pay reewal compesatio Effective o origial effective date if requested withi 60 days of origial effective date If requested more tha 60 days after issue, effective date is approval date how date of dropped coverage Prit ew policy ad ew chedule Page ame policy umber All beefits keep origial issue age Cotiuig beefits cotiue to pay reewal compesatio Effective o origial effective date if requested withi 60 days of origial effective date If chage is requested more tha 60 days after issue, effective date is the policy reewal date o or followig the approval date how date of reductio Prit ew chedule Page ame policy umber No uderwritig required Lifetime premium at origial age No credit give for paymet made durig limited pay period Pay reewal commissios based o lifetime premium payig period Effective o origial effective date if chage requested withi 60 days of origial effective date If chage requested more tha 60 days after issue, effective date is the policy reewal date o or followig approval date Prit ew policy ad chedule Page ectio 3 13

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Geeral Uderwritig Guidelies Policy Uderwritig Applicatio The applicatio packet icludes the applicatio ad ay vital state forms. The applicatio must be take o the cliet s residet state applicatio packet. ubmissio of a oresidet state applicatio will require submissio of the correct state applicatio before a policy ca be issued. The aget must be licesed i the sigig state. Applicatio Received ate The applicatio must be received i our ervice Office withi 30 days of the applicatio date. Applicatios more tha 30 days old whe received will require a curretly dated applicatio. Premium will be based o the applicat s age as of the ew applicatio sigig date. Active uty Military The applicat must be i the Uited tates whe the applicatio is siged, the iterview completed ad the policy delivered. Foreig travel requiremets will ot apply. Beefit ecreases Beefit decreases are allowed. Refer to the owgrades/premium Payig Period Chages chart i the Admiistrative Hadlig sectio. Beefit Icreases Beefit icreases may be allowed withi 60 days after policy issue subject to uderwritig approval. A completed tatemet of Good Health (M24181) is required. Coverage Effective ate (if policy is issued) There are three optios that may be selected o the applicatio: The date of the applicatio (cash with applicatio) The date of policy issue (with or without cash with applicatio) If a replacemet, up to 60 days from the applicatio date, but ot prior to the applicatio sigig date ectio 4 No coverage will be i effect before the Coverage Effective ate. omestic Parters or Parties to a Civil Uio Are eligible for pouse ad Married premium allowaces ad spouse policy beefits. Foreig Natioals Policies will ot be issued to Foreig Natioals livig i the Uited tates for less tha 36 cotiuous moths or to those who do ot have a valid Permaet Residet Card Form I-551 ( Gree Card ). Iclude the Foreig Natioal ad Foreig Travel Questioaire (L5719) with the applicatios for applicats who meet residecy requiremets. Foreig Travel The applicat must be i the U.. to complete their applicatio ad iterview ad to accept delivery of their policy. Those travelig to a OFAC actioed Coutry are ieligible for coverage. 15

Iitial Premium ubmit the full iitial modal premium. Two moths for mothly bak draft. Available modes iclude: 16 Mothly EFT Quarterly emiaual Aual Issue Ages 18-79 Noforfeiture/horteed Beefit Period The Noforfeiture/horteed Beefit Period MUT be offered. If ot chose, the Cotiget Noforfeiture Beefit will be added. Replacemets Replacemets require full uderwritig. A replacemet form must be submitted for all applicats replacig other policies. The prior coverage must be show o the applicatio. Reistatemets A cliet may be eligible for reistatemet of their policy if their attaied age is less tha 72 ad the policy has bee lapsed for less tha 180 days. The former isured should cotact Customer ervice to iitiate the reistatemet. They will be mailed a applicatio for completio. The uderwriter may or may ot require a curret phoe iterview ad medical records. If reistatemet is approved, the cliet must pay all back premium withi 35 days of reistatemet approval. If moey is ot received timely, the cliet is ieligible for reistatemet ad must reapply for coverage with premium at curret age. ave Age Premium will be based upo the applicat s age o the date the applicatio is siged. If the applicat s date of birth is withi 30 days of the applicatio sigig date, rates will be based upo the youger age. uitability A completed Log-Term Care Persoal Worksheet is icluded i each applicatio packet ad must be submitted with each applicatio. The aget is resposible for verifyig that the coverage is affordable for the applicat. Miimum fiacial guidelies are a aual household icome of $16,000 or $50,000 i coutable assets. This policy is ot available to a idividual who meets Medicaid eligibility guidelies. If the applicat does ot disclose their fiacial iformatio, or if the disclosed fiacial iformatio idicates the policy is ot suitable, the applicat will be set a letter requirig them to respod ad advise whether or ot they wat to cotiue with the applicatio. Applicatio Completio The applicatio packet icludes the applicatio ad ay vital state forms. The applicatio must be take o the cliet s residet state applicatio packet. ubmissio of a oresidet state applicatio will require submissio of the correct state applicatio before a policy ca be issued. The aget must be licesed i the sigig state. Two applicats are allowed per applicatio. Oly the applicats for isurace may complete ad sig the applicatio. White out is ot allowed. If a questio is aswered i error, draw a sigle lie through the error, ad have the correctio iitialed by the applicat. N/A is a uacceptable aswer. Istead the questios should be aswered o or oe. Iclude a copy of isured s quote with the applicatio packet.

Idicate o the applicatio the best time to cotact the applicat for a telephoe iterview or face-to-face examiatio. Iform the applicat of the iterview or face-to-face process, provide them with, ad help them complete the Preparig for the Health Iterview form (M26798) located i the Cosumer Guide (applicatio book). It is recommeded that prior to leavig your cliet you call 1-866-544-1617, idetify yourself as the aget ad itroduce your cliet to the service represetative. If a urse is available, a o the spot iterview ca be doe. If a urse is ot available, or if it is ot a coveiet time for the applicat, a appoitmet ca be made for a future date. Otherwise your cliet will be called to schedule a iterview after the applicatio is received. No-Witessed Applicatios No-witessed applicatios are those completed via mail ad telephoe. The Aget must be licesed i the state where the applicatio is completed ad siged. Aswer Questio 2 o the Producer tatemet I certify that each questio was asked exactly as writte ad recorded the aswers completely ad accurately i the presece of the Proposed Isured as o O the lie ext to If o, explai idicate that the applicatio was completed over the telephoe A AP will be required for all applicats A cogitive iterview will be required for all applicats Uderwritig Requiremets All uderwritig requiremets will be ordered by uderwritig oce a applicatio is received. Telephoe Iterview Required for every applicat age 71 ad uder. We recommed you call to schedule a telephoe iterview at the time of sale. Call 1-866-544-1617 ad idetify yourself as the aget ad itroduce your cliet to the service represetative. If a urse is available, a o the spot iterview ca be doe. If a urse is ot available, or if it is ot a coveiet time for the applicat, a appoitmet ca be made for a future date. Face-to-Face Required for every applicat age 72 ad above. Youger ages at uderwriter discretio. ectio 4 Review ad leave with the applicat a copy of the Preparig for the Health Iterview form. Note: If a applicat s hearig loss prevets them from completig a telephoe iterview, a ote should be icluded with the applicatio advisig that a face-to-face examiatio is eeded. For deaf applicats, idicate if they are able to read lips or commuicate with sig laguage. The face-to-face examiatio must be completed i the applicat s home. It caot be completed at their place of work, a relative s home, or a public place such as a restaurat. 17

Medical Records Will be ordered o all applicats age 70 ad above. Medical records o youger ages will be ordered at uderwritig discretio. Ay coditio listed i the Medical Impairmets sectio as Class I or IC will ormally require medical records. Note: A doctor visit is required withi the 24 moths precedig the applicatio date for all applicats age 72 or greater, or those wishig to qualify for a Preferred Rate Class Telephoe Iterview Cogitive (telephoic or face-to-face) Ages 18-71 Ages 65-79 Youger ages if history of CVA, TIA, memory loss, depressio, applicatio was mailed Face-to-Face Iterview Ages 72-79 Youger ages at uderwriter discretio Medical Records Ages 70-79 Youger ages at uderwriter discretio, applicatio was mailed No-Eglish peakig Applicats Whe completig a applicatio o a o-eglish speakig applicat, a iterpreter must be preset to iterpret all of the questios o the applicatio. The iterpreter will be required to tell the aget all of the iformatio give as respose so the aget ca properly complete the applicatio The iterpreter will also be required to traslate for the applicat all of the commets made by the aget, as well as iformatio cotaied i all of our marketig material ad forms The aget, with the assistace of the iterpreter, will also ask the applicat to sig the applicatio ad the Producer or Witess Certificatio form (MLU25947) Our policy allows agets to serve as our iterpreters if they are fluet i the same laguage as the applicat If the aget ad the applicat are ot fluet i the same laguage, it will be the resposibility of the applicat to have a iterpreter available to meet with the aget whe the applicatio is completed. The applicat may choose a iterpreter, but the iterpreter caot be a family member, beeficiary or someoe who would beefit from the issuace of our policy Iclude a ote with the applicatio that a traslator will be eeded for the iterview ad idicate what laguage Uderwritig Philosophy The uderwritig philosophy of Mutual of Omaha s Log-Term Care Uderwritig epartmet ivolves evaluatio of the applicat s health history, cogitive status, daily activities, ad the ability to perform ad maitai Activities of aily Livig (AL s) ad Istrumetal Activities of aily Livig (IAL s). The applicatio idetifies impairmets that will disqualify the applicat from coverage. A applicatio should NOT be submitted for a applicat who aswers yes to a health isurability questio. A policy will ot be issued if the applicat is over or uder the height ad weight guidelies. Multiple health coditios require evaluatio o a case-by-case basis. Higher risk applicats may receive a offer for reduced beefits ad/or may require a premium icrease. The aget will be otified of ay offers that are differet tha as applied. AL s Eatig Toiletig Trasferrig Bathig ressig Cotiece Usig the telephoe Walkig outdoors Climbig stairs Readig/writig Trasportatio IAL s hoppig Meal preparatio Housework Laudry Maagig moey Takig medicatio 18

A applicat with ay of the followig is ieligible for coverage. Aswers yes to a health isurability questio o the applicatio Requires assistace with ay AL s Requires assistace with ay IAL s Receivig Meals o Wheels Is pregat Is disabled Uses a quad cae, crutches, walker, electric scooter, wheelchair, oxyge, or respirator Is o-compliat with medicatios ad/or treatmet Has ot pursued additioal workup recommeded by their physicia Has a coditio listed as a eclie i the Medical Impairmet Guide I the last 6 moths has Bee cofied to a ursig home or assisted livig facility Received home health care services, or adult day care Received occupatioal, physical or speech therapy (pre-qualify the case with a uderwriter if you believe the case may warrat review sooer tha six moths) Rate Classes Refer to the Medical Impairmets sectio ad Build Chart to help determie the appropriate rate class. It is recommeded that a applicat ever be quoted better tha elect. The uderwriter will add a Preferred discout to the policy where appropriate. Applicatios should ot be submitted for persos who are over or uder the weight guidelies, are takig a medicatio, or have a health coditio idicated as uisurable. Preferred 15 percet discout at uderwriter discretio. Refer to Preferred Criteria elect 100% Class I 125% Class II 150% ectio 4 Note: Maximum allowable beefits for Class I ad II risks is a five-year (60 moths) Maximum Lifetime Beefit ad a miimum 90-day Elimiatio Period The followig beefit optios are ot available to Class I ad Class II risks: pouse ecurity Beefit pouse Waiver of Premium pouse urvivorship Beefit pouse hared Care (is available for Class I risks with a Maximum Lifetime Beefit of three years (36 Moths) or less) Waiver of Elimiatio Period for Home Health Care 10- ad 20-Year Premium Optio To-Age-65 Premium Optio igle Premium Optio 19

Preferred Criteria Applicat must meet ALL of the followig criteria to receive Preferred. The determiatio to offer Preferred will be made by the uderwriter. Agets are strogly ecouraged to ever quote a case better tha elect. 1. Tobacco free for the past two years 2. Is ot takig ay prescriptio medicatios other tha: Allergy medicatios (excludig steroids) Female hormoe replacemet Thyroid hormoe replacemet Atacids ad heartbur medicatios Medicatio for cotrolled high blood pressure (readigs of 140/90 or less for the past six moths) Medicatio for cotrolled cholesterol (cholesterol <250) Medicatio for temporary, acute coditios 3. Applicat must ot have bee diagosed or treated for ay of the followig withi the last 5 years: Balace disorder, difficulty walkig or weakess Blood disease or disorder Circulatory disease or disorder, icludig, but ot limited to Peripheral Vascular isease, troke, TIA iabetes Fibromyalgia Heart disease (excludig cotrolled high blood pressure or mild mitral valve prolapse) Kidey or liver disease or disorder Neurological disease or disorder Osteoporosis Paget s isease Respiratory disease or disorder, icludig, but ot limited to Asthma, COP, Emphysema Rheumatoid arthritis 4. No use of a cae 5. Has ot bee declied, rated or deied reistatemet for log-term care isurace withi the past three years 6. Has see their physicia for a checkup ad blood work withi the last two years 7. Height ad weight must be withi the miimum ad preferred maximum rage o the Build Chart 8. The followig health coditios may qualify for Preferred: Osteoarthritis age <60, o oe osteroidal medicatio Osteopeia (T score -2.4 or better) Osteoporosis age <60, T score -2.9 or better, regular exercise program, takig atiresorptive medicatio 9. Ay history of cacer (excludig basal cell ski cacer) does ot qualify for Preferred 20

Build Chart Uisex Height Miimum Preferred Maximum elect Maximum Class I Maximum 5'0" 93 153 189 220 5'1" 95 158 195 227 5'2" 96 164 202 235 5'3" 98 169 208 242 5'4" 101 174 215 250 5'5" 104 180 222 258 5'6" 106 186 229 266 5'7" 110 191 236 274 5'8" 113 197 243 282 5'9" 117 203 250 291 5'10" 121 209 257 299 5'11" 124 215 265 308 6'0" 128 221 272 316 6'1" 132 227 280 320 6'2" 136 233 287 326 6'3" 139 240 295 330 6'4" 142 246 300 344 6'5" 144 253 312 350 6'6" 148 260 320 360 ectio 4 A applicat below the miimum weight is ieligible for coverage. A applicat who is withi the weight requiremets but has other health coditios may be ieligible for coverage. A applicat who exceeds the maximum elect weight ad has ay coditio listed o the impairmet guide as a Class I or IC will be declied. A applicat above the Class I Maximum weight is ieligible for coverage. 21

22

Health-Related Uderwritig Guidelies Uisurable Health Coditios Acoustic Neuroma (uoperated) Acromegaly AL eficit AI/ARC Adult ay Care withi 6 moths Agoraphobia Alcohol 4 or more driks daily Alcoholism with ay curret alcohol use AL Alzheimer s isease Amputatio due to disease Amputatio 2 or more limbs Akylosig podylitis Aorexia Aplastic Aemia Arold-Chiari Malformatio (uoperated) Arrhythmia (ucotrolled) Arterioveous Malformatio (AVM) (uoperated) Arthritis requirig arcotic pai medicatio Asperger s ydrome Assisted Livig Facility (residet withi 6 moths) Ataxia Avascular Necrosis (uoperated) Back Pai (disablig or requirig arcotic pai medicatio) Bell s Palsy (preset) Beig Positioal Vertigo (BPV) (with falls) Bipolar (diagosed withi 3 years, psychiatric hospitalizatio withi 2 years, 2 or more psychiatric hospitalizatios) Blidess (ot adapted or with AL/IAL limitatios) Bowel Icotiece Brached Retial Vei Occlusio (2 or more) Buerger s isease Bulimia Bullous Pemphigoid (active) Cardiomyopathy (dilated) Cerebral Aeurysm (uoperated) Cerebral Palsy Cerebrovascular Accidet (CVA) (2 or more) Charcot Marie Tooth Chroic Pai (requirig arcotics, TEN uit, implatable stimulator, AL/IAL deficit) Cirrhosis Complex Regioal Pai ydrome Cofusio Coective Tissue isease Cor Pulmoale CRET ydrome Croh s (multiple flares or with complicatios) Cushig s ydrome Cystic Fibrosis efibrillator (implated) emetia ermatomyositis iabetic Complicatios (europathy, ephropathy, retiopathy, gastropathy) ialysis ilated Cardiomyopathy isabled ow s ydrome ystoia Epilepsy (>2 seizures/year) Epstei-Barr Virus (withi 2 years) Fibromuscular ysplasia Fibromyalgia (disablig) Frailty Friedrich s Ataxia Glomeruloephritis Head Ijury (residual fuctioal or cogitive impairmet) Heart Trasplat Hemiplegia Hemophilia Hepatitis (chroic, active, alcohol related, residual liver damage) HIV Positive Home Health Care (withi 6 moths) Hutigto s Chorea Hydrocephalus IAL eficit Immue eficiecy Implatable timulator Irritable Bowel ydrome (ucotrolled or with weight loss) Kidey Failure Kidey Trasplat Lacuar Ifarct (2 or more) Liver Trasplat Lou Gehrig s isease Lupus (systemic) Marfa s ydrome Medicaid Recipiet Memory Loss Metal Retardatio Mixed Coective Tissue isease Multiple Myeloma Multiple clerosis Muscular ystrophy Myelodysplasia 23 ectio 5

Uisurable Health Coditios (cotiued) Myelofibrosis Myastheia Gravis (geeralized) Neurofibromatosis Neurogeic Bowel or Bladder Neuropathy (related to diabetes or alcohol, or with history of falls or ski ulcers) Nursig Home residet (withi 6 moths) Orga Trasplat Orgaic Brai ydrome Osteoporosis (T score -3.5 or worse) Oxyge use Pacreas Trasplat Pacreatitis (alcohol related, or >2 episodes) Paralysis Paraplegia Parkiso s isease Pemphigus Vulgaris Physical Therapy (withi 6 moths*) *cotact Uderwritig to prequalify if withi 6 moths Pick s isease Polycystic Kidey isease Polymyositis Polyeuropathy Post Herpetic Neuralgia Post Polio ydrome (with progressive weakess, fatigue, or limitatios) Pregacy Psychiatric Hospitalizatio (withi 3 years, or 2 or more) Psychosis Pulmoary Hypertesio Quad Cae use Quadriplegia Reflex ympathetic ystrophy chizophreia cleroderma higles (withi 6 moths) jogre s ydrome (systemic) ocial Withdrawal pia Bifida troke (2 or more) urgery (requirig geeral aesthesia scheduled or plaed) ystemic Lupus Thalassemia Major Thrombocytosis Trasiet Ischemic Attack (TIA) (2 or more) Tuberculosis Uderweight Vetriculoperitoeal shut Vo Willebrad s isease Walker use Wegeer s Graulomatosis Weight loss (uitetioal or uexplaied) Wheelchair use 24

ome Medicatios Associated With Uisurable Health Coditios This list is ot all-iclusive. A applicatio should ot be submitted if a cliet is takig ay of the followig medicatios. Medicatio Coditio Medicatio Coditio 3TC HIV Kemadri Parkiso s Alkera Cacer Amatadie Parkiso s Lasix Heart isease Apoky Parkiso s >60 mg/day Aptivus HIV L-opa Parkiso s Aricept emetia Letairis Pulmoary Hypertesio Artae emetia Lexiva HIV Atripla HIV Leukera Immuosuppressio Aviza Chroic Pai Levodopa Parkiso s Avoex Multiple clerosis Lioresal Multiple clerosis Azilect Parkiso s Lomustie Cacer AZT HIV Megace Cacer Baclofe Multiple clerosis Megestrol Cacer Baraclude Hepatitis B Mellaril Psychosis Betasero Multiple clerosis Melphala Cacer Mematie emetia Carbidopa Parkiso s Methadoe Chroic Pai, rug Abuse Cerefoli Memory Loss Methotrexate Rheumatoid Arthritis Cogeti Parkiso s >25 mg/week Cogex emetia Myerla Cacer Combivir HIV Comta Parkiso s Nameda emetia Copaxoe Multiple clerosis Narcotics Chroic Pai Crixiva HIV Navae Psychosis Cytoxa Cacer, severe Arthritis Natrecor CHF Nelfiavir HIV 4T HIV Neoral Immuosuppressio C HIV Neupro Parkiso s I HIV Norvir HIV E Cacer Novatroe Multiple clerosis uoneb COP Oxycodoe Chroic Pai Eldepryl Parkiso s Oxycoti Chroic Pai Eligard Prostate Cacer Emtriva HIV Paraplati Cacer Epivir HIV Parlodel Parkiso s Epoge Kidey Failure, HIV Pegasys Hepatitis C Epzicom HIV Peg-Itro Hepatitis C Ergoloid emetia Percocet Chroic Pai Exelo emetia, Parkiso s Percoda Chroic Pai Permax Parkiso s Furosemide Heart/Kidey isease Predisoe COP, Arthritis >60 mg/day >10 mg/day Fuzeo HIV Prezista HIV Procrit Kidey Failure, HIV Galatamie emetia Prolixi Psychosis Geodo chizophreia Gold Rheumatoid Arthritis Razadye emetia Rebetol Hepatitis C Haldol Psychosis Rebif Multiple clerosis Hepsera Hepatitis B Remiyl emetia Hercepti Cacer Remoduli Pulmoary Hypertesio Hydrea Cacer Requip Parkiso s Hydergie emetia Rescriptor HIV Retrovir HIV Imura Immuosuppressio Reyataz HIV Isuli iabetes Riluzole AL >50 uits/day Risperdal Psychosis Iterfero HIV, Hepatitis, Multiple Ritoavir HIV clerosis Idiavir HIV adimmue Immuosuppressio Ivega chizophreia elzetry HIV Ivirase HIV iemet Parkiso s omavert Acromegaly Kaletra HIV talevo Parkiso s telazie Psychosis 25 ectio 5

ome Medicatios Associated With Uisurable Health Coditios (cotiued) Medicatio ustiva ymmetrel Tacrie Tasmar Teslac Thiotepa Thorazie Trelstar-LA Trizivir Truvada TYABRI Tyzeka Valycte Coditio HIV Parkiso s emetia Parkiso s Cacer Cacer Psychosis Prostate Cacer HIV HIV Multiple clerosis Hepatitis B CMV HIV Medicatio VePesid Vicodi Videx Vicristie Viracept Viramue Viread Zaosar Zelapar Zelodox Zerit Ziage Ziprasidoe Coditio Cacer Chroic Pai HIV Cacer HIV HIV HIV Cacer Parkiso s chizophreia HIV HIV chizophreia Alzheimer s isease/emetia Multiple clerosis Parkiso s isease Aricept Hydergie Avoex Amatadie Artae Mematie Baclofe Carbidopa Mirapex Cogex Metrifoate Betasero Cogeti Parlodel Ergoloid Nameda Copaxoe Eldepryl Permax Exelo Tacrie Lioresal Kemadri Requip Galatamie Rebif L-opa iemet Razadye Levodopa ymmetrel Remiyl 26

Uisurable Health Combiatios All shaded health coditio combiatios are ieligible for coverage. Refer to the Medical Impairmets sectio for hadlig of ushaded health coditio combiatios. Atrial Fibrillatio Atrial Fibrillatio troke TIA VH iabetes PV Carotid teosis Tobacco use i the past 12 moths troke Trasiet Ischemic Attack (TIA) Valvular Heart isease (VH) iabetes Peripheral Vascular isease (PV) Carotid teosis Average BP readig >159/89 Tobacco use i the past 12 moths ectio 5 27

Medical Impairmets Every attempt will be made to offer coverage. Multiple medical coditios may result i a offer of reduced beefits, a substadard ratig, or a declie. Coditios listed as Class I or IC will ormally require a Attedig Physicia s tatemet (AP). tadard coverage issued at stadard rates Class I 25 percet ratig maximum beefit period of five years, miimum elimiatio period of 90 days Class II 50 percet ratig may be offered by uderwritig whe multiple medical impairmets are preset, Maximum Lifetime Beefit of five years (60 Moths), miimum Elimiatio Period of 90 days IC Idividual Cosideratio eclie Abdomial Aortic Aeurysm (AAA) Operated, after 6 moths, fully recovered................................................... Uoperated, stable for 2 years, diameter <5 cm... Uoperated, elargig, or diameter >5 cm... Acoustic Neuroma surgically removed, after 6 moths, o residuals... Uoperated... Acromegaly... Addiso s isease, after 3 years, cotrolled... After 12 moths, cotrolled... AL eficit... AI/ARC... Adult ay Care withi 6 moths.... Agoraphobia... Alcohol regular cosumptio of 4 or more driks per day... Advised by a physicia to limit, or stop alcohol cosumptio due to alcohol iduced health or social problems.... Alcoholism recovered at least 3 years, active i a support group, ad o curret alcohol use... till drikig... AL (Amyotrophic Lateral clerosis, Lou Gehrig s isease)... Alzheimer s isease... Amaurosis Fugax.... Amesia, Trasiet Global.... Amputatio due to trauma, after 12 moths, oe limb, o limitatios... ue to disease... Two or more limbs.... Akylosig podylitis... Aemia cause idetified... Not fully evaluated, cause ukow, or Aplastic... Agia... Class 1-IC see TIA see TIA -IC see CA 28

Medical Impairmets (cotiued) Agioplasty... Aeurysm operated, after 6 moths, fully recovered.... Other tha Cerebral, uoperated, stable for 2 years.... Cerebral, uoperated... Aorexia... see CA IC Axiety < 70 years of age, after 12 moths, cotrolled with medicatio, fully fuctioal.... >70 years of age, after 2 years, cotrolled with medicatio, fully fuctioal, o psychiatric hospitalizatios i the past 3 years.... -IC Aortic Isufficiecy.... Atiphospholipid ydrome.... With history of TIA or troke.... Arold-Chiari Malformatio surgically corrected, after 3 years... Uoperated... Arrhythmia excludig Atrial Fibrillatio Cotrolled... Ucotrolled... see Heart Valve isorder Class I IC -IC Arterioveous Malformatio (AVM) >1 year sice surgical repair, o residuals................................................... Class I Uoperated, or operated with residual impairmet.... Arthritis after 1 year Mild, cotrolled, o AL/IAL deficits... Moderate, cotrolled, o AL/IAL deficits... evere, ucotrolled, or AL/IAL deficits... Rheumatoid Arthritis mild, moderate, stable for 1 year, o limitatios.... O Predisoe >10mg/day, or Methotrexate >25mgs week, or Gold... evere disease, or with AL/IAL deficits... Ay, takig a medicatio idicated for severe arthritis o uisurable medicatio list, requirig daily arcotics.... Asbestosis... Asperger s ydrome... Asthma... Assisted Livig Facility Residet withi 6 moths... Ataxia or Muscular Icoordiatio... Atrial Fibrillatio/Flutter sigle episode, after 6 moths, cotrolled o medicatio... Chroic, after 6 moths, cotrolled o Coumadi... iagosed or hospitalized withi 6 moths... With history of TIA, CVA, or Heart Valve isorder.... Chroic, ot o Coumadi.... Average BP readig >159/89... Avascular Necrosis, after 12 moths, treated o residual limitatios... Utreated or with ay limitatios... urgically repaired, o limitatios, after 1 year.... Class I Class I-IC see COP see COP Class I IC ectio 5 29

Medical Impairmets (cotiued) Back Pai/trai sigle episode, ot disablig.... Chroic, ot disablig... Chroic, disablig, or epidural steroid ijectios withi 6 moths... Balace isorder, after 6 moths, resolved... Less tha 6 moths, or curretly preset... Bell s Palsy resolved.... Preset... Beig Positioal Vertigo (BPV) Not associated with falls... Associated with falls.... -1C -IC Bipolar After 3 years, cotrolled o medicatio, fully fuctioal.... <3 years duratio, or psychiatric hospitalizatio withi the past 5 years... Blidess Fully adapted, idepedet with AL/IALs.... Not adapted or with AL/IAL limitatios... Brached Retial Vei Occlusio igle... Two or more... Broke Boes... Brai Attack... Brochitis... Brochiectasis... Buerger s isease.... Bulimia... Bullous Pemphigoid i remissio 2 years, ot o steroids... Active disease... Cacer surgically removed, or fully treated, full recovery, o recurrece... Bladder, trasitioal, treated, fully recovered Ivasive, after 3 years... Recurret... Breast I situ, treatmet completed... tage I, after 1 year.... tage II-III, after 2 years... tage IV, after 5 years... Colo, after 2 years... ki Basal cell... quamous cell... Melaoma tage I or Clark s Level I-V, after 3 moths... tage II or III, after 2 years... tage IV, after 5 years... see Fracture see CVA see COP see COP IC IC IC Class I-IC -IC Class I-IC 30

Medical Impairmets (cotiued) Prostate tage A or B, after 12 moths, surgically removed, curret PA <0.1.... Treated with radiatio, after 12 moths, curret PA <0.5... tage C, after 2 years, curret PA <0.1... tage... Age >70 receivig hormoe treatmet (Lupro, Casodex, Eulixi, Zoladex), Iitial Gleaso core < VI, ad curret PA < 0.5... All other cacers, or multiple sites or metastatic, 2 years sice date of last treatmet, o curret evidece of disease... Ay cacer, 2 years sice date of last treatmet, o curret evidece of disease, tobacco use withi 12 moths............................................................. Cardiomyopathy hypertrophic, o CHF, o hospital stays, sycope, or palpitatios Ejectio fractio >45% ad stable for 2 years... ilated... Class I- IC- Class I- Class I-IC Carotid Artery isease/teosis operated, fully recovered, after 6 moths, tobacco free 12 moths... Operated, tobacco use withi 12 moths... Class I-IC Uoperated, <70% steosis, o symptoms, tobacco free 12 moths............................. Uoperated, <70% steosis, o symptoms, tobacco use withi 12 moths... IC- History of TIA or CVA, or valvular heart disease... Operated or uoperated i combiatio with Type I or Type II diabetes, <70% steosis, tobacco free 12 moths.... Class I <70% steosis, tobacco use withi 12 moths... >70% steosis... Cerebral Palsy... Cerebrovascular Accidet (CVA)... Cerebrovascular isease Brai imagig fidigs of lacuar ifarcts, small vessel ischemia, or white matter chages... Cervical podylosis Mild... Moderate to severe... Charcot Marie Tooth.... Claudicatio... Chroic Brochitis..................................................................... Chroic Fatigue, after 12 moths, o fuctioal limitatios... Ay fuctioal limitatios... Chroic Hepatitis... Chroic Pai Requirig daily arcotics or TEN Uit or implatable stimulator or with AL/IAL limitatios or with epidural steroid ijectio withi 6 moths.... All others... Chroic Regioal Pai ydrome.... see troke Class I-IC see Peripheral Vascular isease see COP IC Lifetime Beefits ot available see Hepatitis Lifetime Beefits ot available IC ectio 5 31

Medical Impairmets (cotiued) Cirrhosis... Collage Vascular isease... Colostomy/Ileostomy, cares for idepedetly, hadle as per cause.... Requires assistace to care for.... Compressio Fractures due to osteoporosis, or with fuctioal limitatios... All others... Cofusio... Coective Tissue isorder.... Cogestive Heart Failure (CHF) sigle episode, recovered, after 12 moths... Chroic, mild, well cotrolled, Lasix <40mg/day.... All others, or i combiatio with atrial fibrillatio, diabetes, or heart valve disorder... COP (Chroic Obstructive Pulmoary isease) Mild, tobacco free for 12 moths... Mild, smoker diagosed by chest X-ray oly, o medicatios, o symptoms, stable Pulmoary Fuctio Tests (PFT s).... Mild or moderate, tobacco use i the past 12 moths, o medicatio, or symptomatic... Moderate, tobacco free for 12 moths, stable PFT s.... Moderate, smoker, o medicatio, or symptomatic.... evere, usig oxyge, or home ebulizer treatmets... Ay, hospitalized for a exacerbatio i the past 6 moths... Ay, FEV1 <65%... Cor Pulmoale... Coroary Artery isease (agia, heart attack, Agioplasty, stet, or Bypass) After 6 moths, stable, o limitatios, o sigificat residual heart damage, tobacco free 12 moths.... After 6 moths, stable, o limitatios, tobacco use withi 12 moths.... With PV... I combiatio with diabetes, tobacco use withi 12 moths... I combiatio with diabetes, tobacco free 12 moths... With poorly cotrolled hypertesio (average BP > 158/89), or cogestive heart failure, or PV, or ejectio fractio < 45%... CPAP... CRET ydrome... Croh s i remissio at least 2 years... After 2 years, 1-2 flares per year... Multiple flares or with complicatios... Cushig s ydrome... Cystic Fibrosis......................................................................... eep Veous Thrombosis, after 6 moths, sigle episode, recovered... Recurret... efibrillator/automatic Implatable Cardiac efibrillator... egeerative isc isease... -IC IC Class I-IC Class I Class I-IC Class I Class I-IC Class II, 2 years 180 day elimiatio period Class I-IC see leep Apea Class I IC- see Heriated isc 32

Medical Impairmets (cotiued) egeerative Joit isease... emetia... emyeliatig isease... epressio ituatioal recovered, treatmet free, after 6 moths, o psychiatric hospitalizatios i the past 3 years... Major <70 years of age, after 12 moths, cotrolled with medicatio, fully fuctioal, o psychiatric hospitalizatios i the past 3 years.... >70 years of age, after 2 years, cotrolled with medicatio, fully fuctioal, o psychiatric hospitalizatios i the past 3 years.... epressio with Electrocoovulsive Therapy (ECT) ECT >10 years ago, fully fuctioal, maitaied o atidepressats, o psychiatric hospitalizatios after ECT... With subsequet psychiatric hospitalizatio.... epressio, ay, 2 or more psychiatric hospitalizatios for ay reaso.... ermatomyositis.... see Arthritis -IC iabetes Type II, cotrolled ad stable with diet ad exercise or oral medicatios, o diabetic complicatios or comorbid coditios, o icrease i dosages or additios of diabetic medicatios for at least 6 moths, tobacco free 12 moths... iabetes Type I or II, cotrolled ad stable, o diabetic complicatios or comorbid coditios, o icrease i dosages or additios of diabetic medicatios for at least 6 moths Tobacco use withi 12 moths... Class I Isuli <50 uits/day.... Class I Isuli >50 uits/day.... I combiatio with: Carotid Artery isease, operated or uoperated <70% steosis, tobacco free 12 moths.... Class I <70% steosis, tobacco use withi 12 moths... >70% steosis.... Retial vei occlusio.... Class II, 2 years, 180 day elimiatio Heart disease, tobacco use withi 12 moths... Class II, 2 years, 180 day elimiatio Heart disease, tobacco free 12 moths... Class I-IC Retiopathy, europathy, or ephropathy... ki ulcers or amputatio... Peripheral Vascular isease, or history of TIA or troke... Average BP readig >158/89... Hemoglobi Alc>9.0, or ocompliat with treatmet.... Microalbuim >20mg/dl... ectio 5 ialysis... ifficulty walkig... isabled, collectig ay type of disability beefits... iverticulitis medically maaged... With bleedig, weight loss, or surgery recommeded......................................... see Balace isorder izziess Beig Positioal Vertigo (BPV), ot associated with falls... BPV associated with falls.... Acute, viral, resolved after 3 moths... All others, withi 6 moths.... After 6 moths, evaluated, resolved... 33

Medical Impairmets (cotiued) After 2 years, ot evaluated, stable with occasioal episodes, ot associated with falls... Multiple episodes, or progressive, or associated with falls... ow s ydrome... rug Abuse treated, active i support group, drug free for 5 years... Withi 5 years... ystoia... Echocardiography Left Atrium >5.0 cm... Ejectio Fractio <45%.... Electric cooter Use... Emphysema... -IC Class I-IC see COP Epilepsy cotrolled with medicatio, o seizures for 1 year.... 1 or 2 seizures per year... Class I Poorly cotrolled... Epstei-Barr Virus 2 years treatmet free, full recovery, o residuals.... <2 years sice treatmet, curretly treated, or preset... Factor V Vo Leide icidetal fidig, or o history of clots... With history of clot, o Coumadi or Warfari.... With history of clot, ot o Coumadi or Warfari... With history of clot while adequately aticoagulated... Faitig... Falls, sigle episode... Multiple episodes, or with ijuries... Fatigue, after 12 moths, resolved... Withi 12 moths, or with fuctioal limitatios... Fibromuscular ysplasia... Fibromyalgia after 1 year, well cotrolled, o AL/IAL deficits... Poorly cotrolled, or disablig... Fracture-Traumatic, oe boe, after 3 moths, fully recovered, o limitatios.... I combiatio with mild osteoporosis.... I combiatio with moderate to severe osteoporosis.... Associated with multiple falls, chroic dizziess, or gait disorder... Fracture-No Traumatic, i combiatio with ay degree of osteoporosis, ot o Atiresorptive medicatio, or with fuctioal impairmet.... Frailty... Friedrich s Ataxia... Gastric Bypass/Badig, after 2 years, fully recovered, o complicatios... Glaucoma, stable visio, cotrolled eye pressures... All others... -Class I Class I see izziess -IC IC- IC- -Lifetime Beefits ot available IC 34

Medical Impairmets (cotiued) Glomeruloephritis... Grave s isease, after 12 moths... Guillai-Barre ydrome, after 12 moths, o residuals... Head Ijury, after 6 moths, o residuals.... With residual fuctioal or cogitive impairmet.... Heart Attack... Heart Valve isorder, operated 1 or 2 valves, fully recovered, after 6 moths... Uoperated, sigle valve, mild, o symptoms, o surgery plaed... Uoperated, sigle valve, moderate to severe, or surgery plaed... Ay, uoperated with Atrial Fibrillatio, or history of TIA or CVA.... Hemochromatosis, after 12 moths, successfully treated with phlebotomy, or chelatio, ad stable blood couts... Hemophilia... Hepatitis, ay chroic, active, or alcohol related, or with residual liver damage... Hepatitis A or B, after 6 moths, fully recovered... Hepatitis C After 2 years, successfully treated with Iterfero, or cleared spotaeously without treatmet, virus udetectable by PCR... Curretly treated, or treated withi 2 years.... Uresposive to Iterfero, or ever treated with Iterfero, or virus ot cleared spotaeously without treatmet... Virus detectable by PCR... Heriated isc/egeerative isc isease () Uoperated, o AL limitatios, ot advised to have surgery... Operated, after 6 moths, full recovery, o hardware... Operated, after 6 moths, full recovery, hardware... Operated or uoperated, requires daily arcotics or implatable stimulator for pai cotrol... Operated or uoperated with AL limitatios.... High Blood Pressure, after 6 moths, compliat with treatmet: Average BP <160/90.... Average BP <170/94.... Average BP >170/94, or ay, ocompliace with treatmet... Hip Replacemet, oe hip after 3 moths, full recovery, o use of assistive devices, o loger receivig physical therapy.... Both hips, fully recovered... urgery recommeded or plaed.... HIV Positive... Hodgki s isease stage I, after 3 years, fully recovered... All others, fully recovered, after 5 years... Home Health Care received withi 6 moths... Hutigto s Chorea... Hydrocephalus with or without shut... Hypothyroidism... -IC see CA -IC IC Class I Class I Class I IC ectio 5 35

Medical Impairmets (cotiued) IAL Impairmet... Idiopathic Thrombocytopeia Purpura (ITP) Platelet cout >50,000 for 1 year... Immue eficiecy.... Implatable timulator... Icotiece, uriary, stress, maages idepedetly... Uriary, ucotrolled, or requires assistace with maagemet... tool... Irritable Bowel ydrome, cotrolled, weight stable... Ucotrolled or with weight loss... Class I Joit Replacemet, oe joit after 3 moths, fully recovered, o use of assistive devices.... 2 or more, fully recovered, o limitatios... Class I-IC urgery recommeded or plaed.... Kidey isorder, mild real isufficiecy, stable 2 years... Moderate to severe... Kidey failure, sigle episode, fully recovered after 2 years.... Kidey Trasplat... Kidey removal (1), after 2 years, with stable kidey fuctio.... Polycystic Kidey isease... ialysis... Chroic Kidey Failure... Kee Replacemet, oe kee after 3 moths, fully recovered, o use of assistive devices, o loger receivig physical therapy.... Both kees, fully recovered... Labrythitis... Lacuar Ifarct igle... igle i combiatio with white matter or small vessel ischemia.... Multiple... Left Atrial Elargemet >5.0 cm.... Leukemia Acute, after 3 years... CLL tage 0 or I, WBC <15,000 for 2 years... tage I-IV... Lou Gehrig s isease.... Lupus, discoid, after 12 moths... ystemic... Lyme isease, after 12 moths, fully recovered, o residuals.... Udergoig treatmet or with residuals... Lymphedema, medically maaged, o limitatios... With limitatios or history of ski ulcers... -IC -IC Class I see izziess see troke IC Class I -IC 36

Medical Impairmets (cotiued) Lymphoma tage I or II, after 2 years, i complete remissio... tage II or IV, after 4 years, i complete remissio.... Low-grade... Macular egeeratio,oe eye... Both eyes... Maic epressio...................................................................... Marfa s ydrome... Medicaid Recipiet... Medullary poge Kidey... Memory Loss... Meiere s isease, after 6 moths, symptoms cotrolled, o limitatios.... Associated with falls.... Meigioma removed, after 12 moths, o limitatios... urgery plaed... Meigitis, after 12 moths, fully recovered... Preset... Metal Retardatio... Mital Valve Prolapse... Mixed Coective Tissue isease... Moocloal Gammopathy, after 1 year.... Multiple Myeloma... Multiple clerosis... Murmur... Muscular ystrophy... Myastheia Gravis, ocular, after 1 year... Geeralized... Myelodysplasia... Myelofibrosis... Myocardial Ifarctio.... Narcolepsy effectively treated... Utreated or resultig i accidets or ijury... NAH Noalcoholic teatohepatitis, after 2 years, ALT <2x ormal, weight withi elect maximum, well cotrolled diabetes (if applicable) ad well cotrolled lipids, ad <3 alcoholic driks per week No fibrosis by liver biopsy.... -IC -IC IC- see Bipolar IC -IC -IC -IC IC- see Heart Valve isorder see Coroary Artery isease -IC Class I ectio 5 37

Medical Impairmets (cotiued) Mild fibrosis... Moderate to severe fibrosis or cirrhosis... Weight above elect maximum.... Neurofibromatosis... Neurogeic Bowel or Bladder... Neuropathy, mild, fully evaluated, o limitatios... Not fully evaluated, related to diabetes or alcohol, or with history of falls, or ski ulcers.... Nursig Home Cofiemet, after 6 moths, full recovery, o limitatios.... Withi 6 moths... Obesity... Obsessive Compulsive isorder, after 3 years, cotrolled o medicatio Fully fuctioal... Limits fuctioal ability... Psychiatric hospitalizatio withi 5 years... Orgaic Brai ydrome... Orga Trasplat... Osteopeia, o medicatio.... Osteoarthritis... Osteomyelitis... Osteoporosis, T score -2.5-2.9, o medicatio, o history of otraumatic fractures... T score -3.0-3.4, o medicatio, o history of otraumatic fractures.... T score -3.5 or worse... Ay with history of otraumatic fracture, or ot o medicatio, or with fuctioal limitatios... Oxyge use... Pacemaker, after 3 moths............................................................... Recommeded or surgery pedig... Paget s isease, o symptoms ad o limitatios... With symptoms or history of fractures... Pacreas Trasplat... Pacreatitis, after 12 moths, sigle episode, fully recovered... Related to alcohol use, or 2 or more episodes.... Paic Attack/isorder... Paralysis... Paraplegia... Parkiso s isease.... Pemphigus Vulgaris... 38 3 years, 180 day elim, Class II-IC -IC IC see Weight chart -IC see Arthritis see Avascular Necrosis Class I -IC IC see Axiety

Medical Impairmets (cotiued) Peripheral Neuropathy... Peripheral Vascular isease Mild, tobacco free 12 moths, o symptoms, o limitatios after 6 moths... Moderate, or i combiatio with coroary artery disease, after 6 moths... evere, or tobacco use withi 12 moths.... Average BP readig >159/89... Ay, with limitatios, history of leg ulcers, TIA, diabetes, pedig surgery, or stet placemet or surgery withi the past 6 moths... Physical Therapy received withi 6 moths.... Pick s isease... Pituitary Adeoma removed, after 12 moths, o limitatios.... table x3 years, o surgery plaed... urgery plaed... Peumoia, after 3 moths, sigle episode, fully recovered... Associated with chroic lug disease... Polio fully recovered, o limitatios, o assistive devices... Fully recovered, o limitatios, leg brace.... With recurrece or limitatios... Post Polio ydrome after 2 years, oprogressive, o limitatios, o assistive devices.... Progressive weakess or fatigue, or with limitatios... Polycystic Kidey isease... Polycythemia Vera after 2 years, maaged with medicatio or Phlebotomy, platelets < 450,000... Polymyalgia Rheumatica mild, after 1 year, o limitatios... Moderate, o fuctioal limitatios... evere, or with limitatios.... Polymyositis/ematomyositis.... Polyeuropathy... Post Herpetic Neuralgia... Post Traumatic tress isorder (PT), after 12 moths, cotrolled, fully fuctioal... After 12 moths, ot adequately cotrolled or with fuctioal impairmet... Pregacy... Udergoig fertility evaluatio or treatmet... Prostate pecific Atige (PA) steadily risig... Risig ad fallig... Psoriasis, mild to moderate, cotrolled with medicatio... evere... Psoriatic Arthritis... Psychosis... see Neuropathy Class I-IC IC see COP IC IC Class II, 2 years 180 day elimiatio Class I-IC -IC -IC IC see Arthritis ectio 5 Pulmoary Edema.... 39

Medical Impairmets (cotiued) Pulmoary Embolism, after 6 moths, sigle episode, fully recovered.... Preset, multiples, or uderlyig coagulatio disorder... Pulmoary Fibrosis, localized, oprogressive, ormal PFT s, after 2 years... Active, progressive disease, abormal PFT s... Pulmoary Hypertesio... Quad Cae Use... Quadriplegia... Reflex ympathetic ystrophy (R)... Real isease/failure... Restless Leg ydrome... Retiitis Pigmetosa.... Rheumatoid Arthritis... arcoidosis............................................................................ ciatica... chizophreia... cleroderma... coliosis Mild... Moderate to severe... eizures... higles, after 6 moths, fully recovered... Preset, or with residuals.... hy-rager ydrome... ickle Cell Aemia... Trait oly, o active disease.... Active disease... jogre s ydrome Mild, dryess of eyes ad mouth oly.... I combiatio with Rheumatoid Arthritis, Coective Tissue isease, or with other orga ivolvemet... ki Cacer... leep Apea resposive to treatmet.... evere or uresposive to treatmet... ocial Withdrawal... pia Bifida... -IC IC see Kidey isorder see Blidess see Arthritis see COP -IC IC see Epilepsy see Cacer 40

Medical Impairmets (cotiued) pial teosis operated, fully recovered, after 12 moths.... Uoperated, mild to moderate... Uoperated, severe or surgery recommeded.... Ay, with epidural ijectios or physical therapy withi 6 moths, or fuctioal limitatios, or chroic pai requirig daily arcotics... troke igle episode, fully recovered after 2 years, o limitatios, tobacco free 12 moths.... Two or more... I combiatio with ay of the followig: Atrial Fibrillatio... Uoperated carotid steosis.... Heart valve disorder... Average blood pressure readig >159/89.... Previous TIA(s)... iabetes... Residual weakess or fuctioal loss... Tobacco use withi the past 12 moths... Ocurred while adequately aticoagulated... urgery, requirig geeral aesthesia, plaed, ot completed... ycope... ystemic Lupus... Temporal Arteritis, after 12 moths, fully recovered... TEN Uit Past use... Curret use... Thalassemia Mior... Major... Thrombocythemia... Thrombocytopeia platelet cout >50,000... Thrombocytosis... Torticollis resolved with Botox, after 6 moths... Tourette s ydrome fully fuctioal, o limitatios... Ay fuctioal limitatios... Trasiet Global Amesia... Trasiet Ischemic Attack (TIA) sigle episode, fully recovered after 1 year.... Two or more... I combiatio with ay of the followig: Atrial Fibrillatio... Uoperated carotid steosis.... Heart valve disorder... Previous stroke... iabetes... Average BP readig >159/89... Residual weakess or fuctioal loss... Tobacco use withi the past 12 moths... Class I-IC Class I see izziess -IC IC Class I 3 years IC see TIA Class I ectio 5 41

Medical Impairmets (cotiued) Occurred while adequately aticoagulated.... Other peripheral vascular disease... Trasverse Myelitis... Tremor fully evaluated, beig familial, o limitatios.... Not fully evaluated, with limitatios, or gait disturbace... Trigemial Neuralgia After 12 moths maaged with atispasmodics or aticovulsats, o limitatios... 6 moths after surgery resolved... Poorly cotrolled or disablig.... Tuberculosis after 12 moths, treated, fully recovered, ormal PFT s.... Preset or with lug damage or other orga ivolvemet... Ulcerative Colitis.... Uderweight... Valvular Heart isease... Vetriculoperitoeal hut... Vertigo... Vo Willebrad s isease.... Walker Use... Weakess... Wegeer s Graulomatosis... Weight Loss, uexplaied, or ot fully evaluated.... Wheelchair Use... Wolff-Parkiso-White ydrome, after 6 moths, ablated, ot preset... Ucotrolled... see Croh s see Heart Valve isorder see izziess 42

tate iffereces Matrix Mutual Care Plus tate pecial Matrix TATE TATE IFFERENCE 1. ALABAMA Natioal rules 2. ALAKA Natioal rules pouse hared Care Beefit caot reduce beefits uder the 3. ARIZONA spouse s policy below 24 moths (istead of atioal s 12 moths) 4. GEORGIA Natioal rules 5. ILLINOI No rate guaratee available. 6. IOWA Natioal rules 7. LOUIIANA Natioal rules 8. MAINE Natioal rules 9. MICHIGAN Natioal rules 10. MINNEOTA Natioal rules 11. MIIIPPI Natioal rules 12. NEBRAKA Natioal rules 13. NEW HAMPHIRE Natioal rules 14. NORTH CAROLINA Natioal rules 15. NORTH AKOTA Natioal rules 16. OKLAHOMA Natioal rules 17. OUTH CAROLINA Natioal rules Miimum NH Mothly Beefit is $3,000.00 18. OUTH AKOTA No 180-day or 365-day Elimiatio Periods. 19. UTAH Natioal rules 20. WET VIRGINIA Natioal rules No Rate guaratee available No imple Iflatio available 21. WICONIN Miimum Nursig Home Mothly Beefit is $1,800 ($60/day X 30 days) - $2,000 is used o the applicatio. 22. WYOMING Natioal rules ectio 6 For Producer Use Oly. Not for use with the geeral public. M26945 4/09 43

Log-Term Care Isurace uderwritte by: Mutual of Omaha Isurace Compay Mutual of Omaha Plaza Omaha, NE 68175 mutualofomaha.com

1-877-894-2478 LONG-TERM CARE INURANCE - OUTLINE OF COVERAGE For Log-Term Care Isurace Form LTC09M Tax-Qualified NOTICE TO BUYER: The policy may ot cover all of the costs associated with log-term care icurred by the buyer durig the period of coverage. The buyer is advised to review carefully all policy limitatios. CAUTION: The issuace of the log-term care isurace policy is based upo the resposes to questios o your applicatio. A copy of your applicatio will be attached to your policy if oe is issued to you. If your aswers are icorrect or utrue, we have the right to dey beefits or rescid the policy. The best time to clear up ay questios is ow, before a claim arises! If, for ay reaso, ay of your aswers are icorrect, cotact us at this address: Mutual of Omaha Isurace Compay, Log-Term Care ervice Office, P.O. Box 64901, t Paul, MN 55164-0901. 1. POLICY EIGNATION This is a idividual policy of isurace to be issued i the state of Illiois. 2. PURPOE OF THE OUTLINE OF COVERAGE This outlie of coverage provides a very brief descriptio of the importat features of the policy. You should compare this outlie of coverage to outlies of coverage for other policies available to you. This is ot a isurace cotract, but oly a summary of coverage. Oly the idividual or group policy cotais goverig cotractual provisios. This meas that the idividual or group policy sets forth i detail the rights ad obligatios of both you ad the isurace compay. Therefore, if you purchase this coverage, or ay other coverage, it is importat that you REA YOUR POLICY CAREFULLY! 3. FEERAL TAX CONEQUENCE The policy is iteded to be federally tax-qualified log-term care isurace uder ectio 7702B(b) of the Iteral Reveue Code of 1986, as ameded. 4. TERM UNER WHICH THE POLICY MAY BE CONTINUE IN FORCE OR ICONTINUE Reewability THI POLICY I GUARANTEE RENEWABLE. This meas you have the right to cotiue the policy i force for as log as you live or util the maximum lifetime beefit is exhausted. ubject to the terms of the policy, we caot cacel your coverage as log as you pay the required premium whe it is due. Mutual of Omaha Isurace Compay caot chage ay of the terms of your policy o its ow, except that, i the future, WE MAY INCREAE THE PREMIUM YOU PAY. Waiver of Premium We will waive the paymet of premium for the policy if you are receivig Nursig Home Beefits, Assisted Livig Facility Beefits or Home Health Care Beefits for, i ay moth, at least eight days of Home Health Care or Adult ay Care. We will waive premium so log as such beefits are payable. The Elimiatio Period must be satisfied before we will waive the paymet of premium for this policy. Ay premium paid for a period for which premiums have bee waived will be credited towards future premium paymets. Whe the waiver period eds, premium paymets will resume for this policy ad must be paid to keep the policy i force. 5. TERM UNER WHICH THE COMPANY MAY CHANGE PREMIUM We reserve the right to icrease the premium for this policy, but ever more tha oce per year. However, ay chage i premium must apply to all policies issued to persos of the same Policy Class. That meas, except whe required by a chage i beefits uder the policy, premium will ot icrease due to a chage i your age or health or your use of the log-term care coverage. We must give you at least 60 days writte otice before we chage premium. 6. TERM UNER WHICH THE POLICY MAY BE RETURNE AN PREMIUM REFUNE a) You may cacel your policy for ay reaso withi 30 days after you receive it. To do so, mail or deliver the policy to either us or to the aget or office through which it was purchased. We will refud the full amout of ay premium paid withi 30 days of such a policy retur: ad the policy will be cosidered ever to have bee issued. M26748_0809 1 Order Number: M26748_INIV_0809

b) The policy cotais a provisio for the retur of ueared premium i the evet of termiatio due to death. Upo receipt of otice that you cacelled your policy or that you have died, we will refud the portio of the premium paid for the period betwee the date of cacellatio or death ad the ext premium due date. We will pay the refud to you or, upo your death, your spouse, if livig, or to your estate. c) The optioal Full Retur of Premium at eath Beefit provides for a refud of premiums upo your death. If the compay receives proof of your death occurrig while your coverage was i force, the total amout of premiums paid for your coverage, from the effective date of the Full Retur of Premium at eath Beefit coverage up to the date of your death may be refuded without iterest. The optioal Retur of Premium at eath Less Claims Beefit provides for a refud of premiums if you die while the policy is i force, less the amout of claims paid uder the policy. We will ot add iterest to the beefit paid uder this beefit. The optioal Retur of Premium (Less Claims Paid) if eath Occurs Before Age 65 Beefit provides for a refud of premiums if you die while the policy is i force but prior to the policy aiversary date coicidig with or ext followig your 65 th birthday. We will ot add iterest to the beefit paid uder this beefit. 7. THI I NOT MEICARE UPPLEMENT COVERAGE If you are eligible for Medicare, review the Guide to Health Isurace for People with Medicare available from Mutual of Omaha Isurace Compay. Neither Mutual of Omaha Isurace Compay or its agets represet Medicare, the federal govermet, or ay state govermet. 8. LONG-TERM CARE COVERAGE Policies of this category are desiged to provide coverage for oe or more ecessary or medically ecessary diagostic, prevetive, therapeutic, rehabilitative, maiteace, or persoal care services, provided i a settig other tha a acute care uit of a hospital, such as i a Nursig Home, i the commuity, or i the Home. This policy reimburses you for expeses you icur for covered log-term care expeses. 9. BENEFIT PROVIE BY THE POLICY Beefits Beefits are available up to the mothly ad lifetime maximum util the applicable maximum lifetime beefit has bee reduced to zero. Refer to your completed applicatio for the level of coverage ad features selected. Care Coordiatio We will pay the eligible expeses made by a Care Coordiator for the followig services: (a) assessig your eed for log-term care services; (b) developig your Pla of Care; (c) coordiatig the delivery of log-term care services; ad (d) if you desire, moitorig the delivery of such log-term care services. The use of Care Coordiatio services is optioal. Except for tay-at-home Beefits ad Alterate Care Beefits, you are ot required to use a Care Coordiator to receive beefits uder the policy. While a Care Coordiator will assist you i idetifyig qualified providers, you are resposible for choosig your log-term care providers. You are ot required to use the providers idetified i ay Pla of Care developed by a Care Coordiator. You do ot eed to satisfy the Elimiatio Period to receive the services of a Care Coordiator. The eligible expeses made by a Care Coordiator will ot reduce your maximum lifetime beefit. Facility Assessmet We will pay the eligible expeses made by a Care Coordiator to assess the safety ad adequacy of the facility i which you are receivig log-term care. The Care Coordiator must provide you or your represetative with a writte report of such facility assessmet. We will pay for such assessmet o more tha oce per caledar year. Nursig Home Beefit We will pay a Nursig Home Beefit if you are cofied to a Nursig Home. The Nursig Home Beefit is equal to the eligible expeses made by a Nursig Home each moth, up to the Nursig Home maximum mothly beefit. Eligible expeses payable uder the Nursig Home Beefit are limited to: (a) room ad board; (b) Acillary ervices; ad (c) patiet supplies provided by the Nursig Home for care of its residets. Eligible expeses do ot iclude Physicia s charges; hospital ad laboratory charges; prescriptio or o-prescriptio medicatio; trasportatio; items ad services furished at your request for comfort, coveiece or etertaimet, such as televisios, telephoes ad beauty care; or guest meals or spouse charges. M26748_0809 2 Order Number: M26748_INIV_0809

Nursig Home Bed Reservatio Beefit If you are cofied to a Nursig Home ad abset for ay reaso other tha discharge, we will cotiue to pay the Nursig Home Beefit as if you were still cofied. This Nursig Home Bed Reservatio Beefit will be paid oly if you have icurred a charge to reserve your place at the Nursig Home. No additioal Nursig Home Bed Reservatio Beefits are payable i ay caledar year oce we have paid Nursig Home Bed Reservatio Beefits for the maximum umber of days (up to 30 days i a caledar year.) Ay uused days caot be carried over ito the ext caledar year. Assisted Livig Facility Beefit We will pay a Assisted Livig Facility Beefit if you are cofied to a Assisted Livig Facility. The Assisted Livig Facility Beefit is equal to the eligible expeses made by a Assisted Livig Facility each moth, up to the Assisted Livig Facility maximum mothly beefit. Eligible expeses payable uder the Assisted Livig Facility Beefit are limited to: (a) room ad board for a oe-bedroom uit; (b) Acillary ervices; ad (c) patiet supplies provided by the Assisted Livig Facility for care of its residets. Eligible expeses do ot iclude Physicia s charges; hospital ad laboratory charges; prescriptio or o-prescriptio medicatio; trasportatio; items ad services furished at your request for comfort, coveiece or etertaimet, such as televisios, telephoes ad beauty care; or guest meals or spouse charges. Assisted Livig Facility Bed Reservatio Beefit If you are cofied to a Assisted Livig Facility ad abset for ay reaso other tha discharge, we will cotiue to pay the Assisted Livig Facility Bed Reservatio as if you were still cofied. This Assisted Livig Facility Bed Reservatio beefit will be paid oly if you have icurred a charge to reserve your place at the Assisted Livig Facility. No additioal Assisted Livig Facility Bed Reservatio Beefits are payable i ay caledar year oce we have paid Assisted Livig Facility Bed Reservatio Beefits for the maximum umber of days (up to 30 days i a caledar year.) Ay uused days caot be carried over ito the ext caledar year. Home Health Care Beefit We will pay a Home Health Care beefit if you receive Home Health Care or Adult ay Care. The Home Health Care Beefit is equal to the eligible expeses icurred by you for Home Health Care or Adult ay Care each moth, up to the Home Health Care maximum mothly beefit amout selected. To be eligible for Home Health Care Beefits, eligible expeses icurred by you for Home Health Care must be provided by a Home Health Care Agecy or idepedet provider ad for Adult ay Care must be provided by a Adult ay Care Ceter. Home Health Care Beefits iclude eligible expeses icurred by you for trasportatio to ad from a Adult ay Care Ceter. Respite Care Beefit I order to provide temporary relief to a upaid caregiver, you may receive Respite Care durig a temporary stay i a Nursig Home or Assisted Livig Facility or i your Home or a Adult ay Care Ceter. Whe you receive Respite Care, we will pay the eligible charges made by a Nursig Home or Assisted Livig Facility or icurred by you for Home Health Care or Adult ay Care each moth, up to the Respite Care maximum mothly beefit. Respite Care Beefits will be paid for o loger tha the period of time selected ad show i your policy schedule. You do ot eed to satisfy the Elimiatio Period to receive Respite Care Beefits. Hospice Care Beefit If you are termially ill, you may receive Hospice Care durig a cofiemet to a Nursig Home or Assisted Livig Facility or i your Home or Adult ay Care Ceter. Whe you receive Hospice Care, we will pay Nursig Home beefits, Assisted Livig Facility beefits ad Home Health Care beefits, without requirig you to satisfy the Elimiatio Period. No additioal Hospice Care beefits are payable if your Physicia ceases to certify you as termially ill. Iteratioal Beefit We will pay a Iteratioal Beefit if you are cofied to a Nursig Home or Assisted Livig Facility or receive Home Health Care or Adult ay Care outside of the Uited tates, its possessios or territories, Caada or the Uited Kigdom. The Iteratioal Beefit is equal to the maximum mothly beefit selected by you. The Iteratioal Beefit is paid each moth you are eligible to receive the Iteratioal Beefit. The Iteratioal Beefit will be paid regardless of whether eligible expeses icurred by you i ay moth are more or less tha the maximum mothly beefit. No additioal Iteratioal Beefits are payable uder this policy oce we have paid Iteratioal Beefits equal to the Iteratioal Beefit Lifetime Maximum. All paymets of Iteratioal Beefits will be made i U.. dollars. tay-at-home Beefits (Available whe you use a Care Coordiator) * We will pay the eligible expeses for tay-at-home Beefits if recommeded by a Care Coordiator. Except for the Caregiver Traiig Beefit, the Care Coordiator must determie that the tay-at-home Beefit is a cost effective alterative to beefits otherwise provided by the policy. We will ot pay eligible expeses icurred prior to the date the Care Coordiator makes such determiatio. M26748_0809 3 Order Number: M26748_INIV_0809

You ca receive tay-at-home Beefits at the same time you receive other beefits uder the policy. No further tay-at- Home Beefits will be paid oce we have paid tay-at-home Beefits i a amout equal to the tay-at-home Lifetime Maximum. (These beefits combied are payable up to two times the Basic/Professioal/Home Health Care maximum mothly beefit.) You do ot eed to satisfy the Elimiatio Period to receive tay-at-home Beefits. * Caregiver Traiig Beefit We will pay the eligible expeses for traiig a Family Member or fried to provide care for you i your Home. To be eligible for this beefit, the traiig must cover the proper use ad care of a therapeutic device or a appropriate care givig procedure by a traier approved by us. We will ot pay to trai someoe who will be paid to care for you. The traiig ca be received while you are cofied i a hospital, Assisted Livig Facility or Nursig Home oly if it is reasoably expected that such traiig will make it possible for you to retur Home where you ca be cared for by the perso receivig the traiig. * urable Medical Equipmet Beefit We will pay the eligible expeses for urable Medical Equipmet. Eligible expeses payable uder the urable Medical Equipmet Beefit are limited to the purchase price of the urable Medical Equipmet or, if such urable Medical Equipmet is ormally reted o a periodic basis, the retal charge. The decisio whether to purchase as opposed to ret urable Medical Equipmet will be made by us at our sole discretio. * Home Modificatio Beefit We will pay the eligible expeses for modificatios to your Home which are iteded to ehace your ability to perform the Activities of aily Livig ad/or allow you to remai i your Home safely. Eligible expeses payable uder the Home Modificatio Beefit are limited to the expeses icurred by you for labor, equipmet, ad supplies. The Home Modificatio Beefit may ot be used solely to icrease the value of your Home. * Medical Alert ystem Beefit We will pay the eligible expeses for a Medical Alert ystem to be istalled i your Home. Eligible expeses payable uder the Medical Alert ystem Beefit are limited to the istallatio ad retal charges for a Medical Alert ystem. Alterate Care Beefit (Available whe you use a Care Coordiator) We may, at our sole discretio, pay a Alterate Care Beefit. A Alterate Care Beefit will be paid if you receive a alterative type of care, treatmet, service or supply for which beefits are ot payable uder the policy. The amout of ay Alterate Care Beefit will be determied by us at time we approve such care. To be eligible for Alterate Care Beefits, a Care Coordiator must recommed the alterative type of care, treatmet, service or supply. The Care Coordiator, your Licesed Health Care Practitioer, you or your represetative ad we must all agree that the alterative type of care appropriately meets your eeds ad is a cost-savig alterative to other beefits provided by the policy. At the time we approved such care, we will determie whether you must satisfy the Elimiatio Period to receive Alterate Care Beefits. Upo writte otice to you or your represetative, we may, at our discretio, discotiue payig you Alterate Care Beefits without affectig your rights to other beefits provided by the policy. Cash Beefit Paymet of Cash Beefits We will pay a Cash Beefit each moth you are Chroically Ill, if you elect this beefit at the time of claim. The amout of the Cash Beefit to be paid each moth is the amout you select ad show i the policy schedule. A Cash Beefit will be paid i advace each moth you are eligible for a Cash Beefit. If we determie you are eligible for a Cash Beefit for less tha a etire moth, we will adjust the Cash Beefit for that moth. The Cash Beefit will be prorated based o the actual umber of days you are eligible for a Cash Beefit i such moth. We will assume that such moth cosists of 30 days regardless of the actual umber of days i such moth. If i ay moth you receive a Cash Beefit i excess of the amout for which you are eligible, we will reduce ay future beefits paid to you uder the policy by the amout of the ueared Cash Beefit. Effect of Receivig Cash Beefits While you are receivig Cash Beefits, o other beefits are payable uder the policy. You may elect to discotiue receivig Cash Beefits by providig writte otice to us. After Cash Beefits have bee discotiued, you may receive ay other beefit offered uder the policy for which you are eligible. If you later decide ot to receive other beefits uder the policy, you may agai elect to receive Cash Beefits. Other Iformatio You do ot eed to satisfy the Elimiatio Period to receive Cash Beefits. We reserve the right to require you to submit a ew Pla of Care at least oce every 60 days while you are receivig Cash Beefits. M26748_0809 4 Order Number: M26748_INIV_0809

Additioal Beefit for Ijury If you elect this optio: You are eligible for a Additioal Beefit for Ijury if, prior to the policy aiversary date coicidig with or ext followig your 65 th birthday, you sustai a ijury which results i your cofiemet to a Nursig Home or Assisted Livig Facility or receivig Home Health Care Beefits. You must sustai such ijury while the policy is i force, but whe you are ot Chroically Ill. To cofirm your eligibility, you must udergo a assessmet withi 90 days of sustaiig ay accidet or trauma. Based o such assessmet, a Licesed Health Care Practitioer must certify that you sustaied a ijury. You will o loger be eligible for the Additioal Beefit for Ijury if a Licesed Health Care Practitioer determies that you are o loger Chroically Ill or you are Chroically Ill for reasos other tha your ijury. We will pay a Additioal Beefit for Ijury ay moth you icur eligible expeses i excess of the Nursig Home Beefits, Assisted Livig Facility Beefits or Home Health Care Beefits paid to you that moth. OPTIONAL BENEFIT You may elect ay of the followig optios to expad the beefits uder the policy: Waiver of Elimiatio Period for Home Health Care Beefit If elected, you do ot eed to satisfy the Elimiatio Period to receive Home Health Care Beefits uder the policy. Restoratio of Beefits If beefits have bee paid uder the policy ad you later become eligible for Restoratio of Beefits, we will restore your maximum lifetime beefit. Except for ay beefits paid for your spouse uder ay pouse hared Care Beefit to the policy, the maximum lifetime beefit will be restored to the amout that would have applied if o beefits had bee paid uder the policy. To be eligible for Restoratio of Beefits, a Licesed Health Care Practitioer must certify that you meet the followig requiremets for a period of 180 cosecutive days: (a) the ability to perform, without ubstatial Assistace from aother idividual, all Activities of aily Livig; ad (b) o eed for ubstatial upervisio by aother perso to protect yourself from threats to health ad safety due to evere Cogitive Impairmet; ad (c) o Physicia or Licesed Health Care Practitioer has iformed you that you require log-term care services. The maximum lifetime beefit will be restored oly oce durig the term of the policy. pouse ecurity Beefit We will pay a pouse ecurity Beefit if you receive other beefits uder the policy. However, we will ot pay a pouse ecurity Beefit if you receive beefits uder ay Cash Beefit rider attached to the policy. The pouse ecurity Beefit is equal to the other policy beefits received by you each moth times 60%. pouse ecurity Beefits will ot reduce the maximum lifetime beefit. pouse Waiver of Premium Beefit You are eligible for this beefit, if both you ad your spouse are covered uder a separate i force Mutual of Omaha Isurace Compay Log-Term Care Isurace policy (Form LTC09M), with a pouse Waiver of Premium rider. We will waive the paymet of your premium for the policy whe ad so log as the premium for your spouse's policy is waived uder the terms of his or her policy. Whe the waiver period uder your spouse's policy eds, premium paymets will resume for your policy ad must be paid to keep your policy i force. A icrease i the premium paid by you for the policy may occur as result of your addig or icreasig a policy beefit followig the policy effective date. We will waive the icreased amout of the premium whe ad so log as the premium for your spouse s policy is waived uder the terms of his or her policy, but oly after the expiratio of the Qualificatio Period (10 years). pouse urvivorship Beefit This beefit is applicable oly if both you ad your spouse are covered uder policy (Form LTC09M) Log-Term Care Isurace Policies with this beefit, ad you ad your spouse are livig o the date the urvivorship Beefit has bee i force for the legth of the Qualificatio Period (10 years), ad both policies are i force. If your spouse dies o or after the date the urvivorship Beefit has bee i force for the legth of the Qualificatio Period, your policy will become paid up effective o its ext policy reewal date ad will cotiue i force without further premium paymets for the rest of your lifetime. The premium for ay beefit added or icreased after the death of your spouse will ot be paid up. M26748_0809 5 Order Number: M26748_INIV_0809

pouse hared Care Beefit If both you ad your spouse are each covered uder a idetical separate i force Mutual of Omaha Isurace Compay's Log-Term Care policy (Form LTC09M), you may draw from your spouse's maximum lifetime beefit to pay beefits uder your policy. Beefits will be paid i accordace with the terms ad coditios i effect uder your policy at the time your maximum lifetime beefit was reduced to zero. The maximum lifetime beefit uder your spouse's policy will be reduced to the extet that you draw agaist it to pay beefits uder your policy. Christia ciece Providers If you are eligible to receive Alterate Care Beefits, we may, at our discretio, pay a Alterate Care Beefit for services: (a) provided by a accredited Christia ciece Nurse listed i the Christia ciece Joural; ad (b) icurred while cofied i a Christia ciece ursig orgaizatio/facility curretly recogized by The Commissio for Accreditatio of Christia ciece Nursig Orgaizatios/Facilities, Ic., or ay comparable accreditig orgaizatio. LIMITE PREMIUM PAYMENT OPTION You may elect ay of the followig optios to pay the premiums for your policy withi a limited time period: igle Premium Paymet Optio If you select this optio, that meas you paid a sigle premium for the policy. You will be required to make o further premium paymets to keep the policy i force. 10-Year Premium Paymet Optio If you select this optio, you will pay premium for the policy for 10 policy years. Except as otherwise provided i the rider, from ad after the 11 th policy aiversary date, you will be required to make o further premium paymets to keep the policy i force. From ad after the 11 th policy aiversary date, you will ot be eligible for ay refud uder the Refud of Ueared Premiums provisio of the policy. If a icrease i premium for the policy occurs as a result of your addig or icreasig a policy beefit, you will pay the amout of the icrease i premium for 10 Policy Years. Thereafter, you will be required to make o further premium paymets to keep the policy i force. 20-Year Premium Paymet Optio If you select this optio, you will pay premium for the policy for 20 policy years. Except as otherwise provided i the rider, from ad after the 21 st policy aiversary date, you will be required to make o further premium paymets to keep the policy i force. From ad after the 21 st policy aiversary date, you will ot be eligible for ay refud uder the Refud of Ueared Premiums provisio of the policy. If a icrease i premium for the policy occurs as a result of your addig or icreasig a policy beefit, you will pay the amout of the icrease i premium for 20 Policy Years. Thereafter, you will be required to make o further premium paymets to keep the policy i force. To-Age-65 Premium Paymet Optio If you select this optio, you will pay premium for the policy util the Paid Up Premium ate. (Paid Up Premium ate meas the policy aiversary date coicidig with or ext followig your 65 th birthday.) Except as otherwise provided i this rider, from ad after the Paid Up Premium ate, you will be required to make o further premium paymets to keep the policy i force. From ad after the Paid Up Premium ate, you will ot be eligible for ay refud uder the Refud of Ueared Premiums provisio of the policy. If a icrease to the premium paid by you for the policy occurs as a result of your addig or icreasig a policy beefit, you will pay the amout of the icrease i premium util the policy aiversary date ext followig the Paid Up Premium ate. Thereafter, you will be required to make o further premium paymets to keep the policy i force. OPTIONAL NONFORFEITURE BENEFIT Noforfeiture Beefit horteed Beefit Period If you elect the optioal Noforfeiture Beefit horteed Beefit Period, your coverage will be exteded as a Noforfeiture Beefit, if your policy lapses due to o-paymet of premium. However, the No-forfeiture Beefit will NOT take effect if your policy lapses before the third policy aiversary date. Uder the Noforfeiture Beefit horteed Beefit Period, we will pay beefits uder the policy i the amouts ad i accordace with the terms of the policy o the date the policy lapsed. However, the maximum lifetime beefit will be M26748_0809 6 Order Number: M26748_INIV_0809

reduced resultig i your beefits beig paid for a shorter legth of time. The maximum lifetime beefit will be reduced to a amout equal to the greater of: (a) the maximum mothly beefit i effect o the date the policy lapsed; or (b) the total amout premiums paid for your policy. The total of all beefits paid uder the policy will ot exceed the maximum lifetime beefit that would have bee paid if your policy did ot lapse. Cotiget Noforfeiture Beefit You will receive coverage uder this beefit if you do ot elect the Noforfeiture Beefit--horteed Beefit Period. Notice of ubstatial Premium Icrease We will otify you of ay icrease i premium for your policy which costitutes a ubstatial Premium Icrease at least 60 days prior to the date your premium will chage. The otice will iclude the amout of the premium ad will offer you the followig optios: (a) You may reduce beefits uder your policy to the level you ca obtai for the premium i effect prior to the icrease, without udergoig additioal uderwritig; or (b) You may elect to receive the Cotiget Noforfeiture Beefit. You have 120 days followig the premium due date to make this electio. If your policy lapses durig the 120 days followig the premium due date, you will be deemed to have made the electio to receive this beefit. If you are also eligible for the Limited Premium Paymet Cotiget Noforfeiture Beefit, you must choose betwee receivig either that beefit or the Cotiget Noforfeiture Beefit. You may ot elect to receive both beefits. Cotiget Noforfeiture Beefit Uder the Cotiget Noforfeiture Beefit, we will pay beefits uder the policy i the amouts ad i accordace with the terms of the policy o the date the policy lapsed. However, the maximum lifetime beefit will be reduced resultig i your beefits beig paid for a shorter legth of time. The maximum lifetime beefit will be reduced to a amout equal to the greater of: (a) the maximum mothly beefit i effect o the date the policy lapsed; or (b) the total amout premiums paid for your policy. The total of all beefits paid uder the policy will ot exceed the maximum lifetime beefit that would have bee paid if your policy did ot lapse. Please refer to the Potetial Rate Icrease isclosure Form to determie whether or ot a chage i premiums costitutes a ubstatial Premium Icrease. ubstatial Premium Icrease meas a cumulative icrease to your aual premium that is equal to or exceeds the percetage of your iitial aual premium as show i the Potetial Rate Icrease isclosure Form ad based o your issue age. ELIGIBILITY FOR THE PAYMENT OF BENEFIT You are eligible for beefits uder the policy if you are Chroically Ill. You are Chroically Ill if, withi the precedig twelve moth period, a Licesed Health Care Practitioer certifies that: (a) You are uable to perform, without ubstatial Assistace from aother perso, at least two Activities of aily Livig for a period that is expected to last at least 90 cosecutive days due to a loss of fuctioal capacity; or (b) You require ubstatial upervisio to protect yourself from threats to health ad safety due to a evere Cogitive Impairmet. EFINITION Activities of aily Livig meas the followig self-care fuctios: Bathig: Washig oeself by spoge bath; or i either a tub or shower, icludig the task of gettig ito or out of the tub or shower. Cotiece: The ability to maitai cotrol of bowel ad bladder fuctio; or, whe uable to maitai cotrol of bowel or bladder fuctio, the ability to perform associated persoal hygiee (icludig carig for catheter or colostomy bag.) ressig: Puttig o ad takig off all items of clothig ad ay ecessary braces, fasteers or artificial limbs. Eatig: Feedig oeself by gettig food ito the body from a receptacle (such as a plate, cup, or table) or by a feedig tube or itraveously. Toiletig: Gettig to ad from the toilet, gettig o ad off the toilet, ad performig associated persoal hygiee. Trasferrig: Movig ito or out of a bed, chair or wheelchair. Adult ay Care meas a program for six or more idividuals of social ad health-related services provided durig the day i a commuity group settig for the purpose of supportig frail, impaired elderly or other disabled adults who ca beefit from care i a group settig outside the Home. M26748_0809 7 Order Number: M26748_INIV_0809

Adult ay Care Ceter meas a facility that is licesed or certified to provide Adult ay Care by the state i which it operates. If the state does ot licese or certify such facilities, the it must meet all of the followig stadards: (a) it provides Adult ay Care i a protective settig ad uder appropriate supervisio; (b) it operates o less tha a 24-hour basis; (c) it keeps a writte record of services for each perso; ad (d) it has established procedures for obtaiig appropriate aid i the evet of a medical emergecy. Alzheimer's Facility meas a specialized facility that is egaged primarily i providig care for persos with Alzheimer's disease or other evere Cogitive Impairmet ad has the appropriate state licesure, certificatio or registratio to operate as a Alzheimer's Facility. Acillary ervices meas physical, occupatioal, speech, ad respiratory therapies, woud care, medicatio maagemet, cotiece care support ad similar care-related services or supplies that support Activities of aily Livig. Assisted Livig Facility meas a facility or distictly separate part of a facility that is egaged primarily i providig o-skilled log term care. If required by the state i which it is located, a Assisted Livig Facility must have the appropriate state licesure, certificatio or registratio to operate as a Assisted Livig Facility. If the state i which it is located does ot require a Assisted Livig Facility to be licesed, certified or registered, the facility must meet the followig requiremets: (a) provides services ad care o a cotiuous 24-hour basis for persos requirig ubstatial Assistace with the Activities of aily Livig or ubstatial upervisio due to evere Cogitive Impairmet; (b) maitais traied staff o duty at all times to provide the services ad care; (c) provides at least three meals a day ad accommodates special dietary eeds; (d) provides residetial services ad Maiteace or Persoal Care ervices i oe locatio; (e) maitais formal arragemets with a Physicia or urse to furish medical care i case of a emergecy; ad (f) maitais appropriate procedures to provide osite assistace with prescriptio medicatios. A Alzheimer s Facility or a Hospice Care Facility may be a Assisted Livig Facility if such facility meets the requiremets cotaied i this defiitio for a Assisted Livig Facility located i a state which does ot require licesure, certificatio or registratio. Assisted Livig Facility does ot iclude a hospital or cliic; a place that operates primarily for the treatmet of alcoholism, drug addictio or metal or ervous disorder; a Nursig Home; a domiciliary care facility; or your primary place of residece i a area used pricipally for idepedet residetial livig; or a similar establishmet. Care Coordiator meas a Licesed Health Care Practitioer who is qualified by traiig ad experiece to assess ad coordiate the overall care eeds of a perso who is Chroically Ill. The care coordiator may provide services idepedet of, or be employed by or uder cotract to, a agecy. uch care coordiator ad/or agecy must be desigated by us as a approved care coordiator. The use of a Care Coordiator is optioal. Chroically Ill has the meaig foud for such term i the ELIGIBILITY FOR BENEFIT sectio of this outlie ad the policy. Elimiatio Period meas the umber of caledar days show i the policy schedule. (Refer to the LIMITATION OR CONITION ON ELIGIBILITY OF BENEFIT sectio of this outlie for additioal iformatio.) Family Member meas your mother, father, so, daughter, brother, sister or spouse. Home meas the place where you maitai your primary idepedet residece. Home does ot iclude: a Nursig Home; a hospital; a Assisted Livig Facility; ay other istitutioal settig where you are depedet o others for assistace with Activities of aily Livig; or the residece of the perso providig the Home Health Care. Home Health Care meas medical ad o-medical services, provided to ill, disabled or ifirm persos i their Homes. uch services iclude, but are ot limited to: (a) part-time or itermittet skilled services provided by a urse; (b) services to support your compliace with your medicatio/treatmet regime; (c) home health aide services; (d) physical therapy, respiratory therapy, occupatioal therapy, speech therapy or audiology therapy; (e) services provided by a specialist i the field of utritio or the admiistratio of chemotherapy; (f) Homemaker ervices; (g) Maiteace or Persoal Care ervices; (h) Respite Care; (i) Hospice Care. M26748_0809 8 Order Number: M26748_INIV_0809

Home Health Care Agecy meas a etity that is regularly egaged i providig Home Health Care for compesatio ad employs staff who are qualified by traiig or experiece to provide such care. The etity must: (a) be supervised by a qualified professioal such as a registered urse (RN), a licesed social worker, or a Physicia; (b) keep cliical records or care plas o all patiets; (c) provide ogoig supervisio ad traiig to its employees appropriate to the services to be provided; ad (d) have the appropriate state licesure, accreditatio or certificatio, where required. Homemaker ervices meas those services eeded to maitai a adequate Home eviromet such as: laudry services; routie food shoppig ad errads; meal preparatio ad cleaup; ad domestic or cleaig services. Hospice Care meas palliative care to alleviate the physical, emotioal ad social discomfort of idividuals who are termially ill. Hospice Care Facility meas a facility which provides Hospice Care uder the directio of a Physicia o a ipatiet basis. A Hospice Care Facility must be licesed or certified by the state i which it is located, if such licese is required. Licesed Health Care Practitioer meas ay of the followig who is ot a Family Member: a Physicia; a registered urse (RN); a licesed social worker; or ay other idividual who meets such requiremets as may be prescribed by the ecretary of the Treasury of the Uited tates. Maiteace or Persoal Care ervices meas ay care the primary purpose of which is the provisio of eeded assistace with helpig you coduct Activities of aily Livig while you are Chroically Ill. This icludes protectio from threats to health ad safety due to evere Cogitive Impairmet. Nursig Home meas a facility or distictly separate part of a facility that is egaged primarily i providig ursig care. If required by the state i which it is located, a Nursig Home must have the appropriate state licesure, certificatio or registratio to operate as a Nursig Home. If the state i which it is located does ot require a Nursig Home to be licesed, certified or registered, the facility must meet the followig requiremets: (a) provides twety-four (24) hour-a-day ursig care uder the supervisio of a licesed practical urse (LPN), registered urse (RN) or a Physicia; (b) maitais a daily medical record of each ipatiet; ad (c) provides ursig care at skilled, itermediate, or custodial levels. A Alzheimer s Facility or a Hospice Care Facility may be a Nursig Home if such facility meets the requiremets cotaied i this defiitio for a Nursig Home located i a state which does ot require licesure, certificatio or registratio. Nursig Home does ot iclude a hospital or cliic; a place which operates primarily for the treatmet of alcoholism, drug addictio, or metal or ervous disorders; a Assisted Livig Facility; a adult residetial care home; a domiciliary care facility; or your primary place of residece i a area used pricipally for idepedet residetial livig; or a similar establishmet. Physicia meas a doctor of medicie or osteopathy legally authorized to practice medicie ad surgery by the state i which he or she performs such fuctio or actio (as defied i ectio 1861 (r) (1) of the ocial ecurity Act) other tha you or a Family Member. He or she must be providig services withi the scope of his or her licese. Pla of Care meas a writte pla of services prescribed for you by a Licesed Health Care Practitioer. We reserve the right to discuss the Pla of Care with the Licesed Health Care Practitioer. We have the right to verify that your Pla of Care is appropriate ad cosistet with geerally accepted stadards for care of the Chroically Ill. The Pla of Care must specify the type, cost, frequecy ad providers of the services you require. The Pla of Care will be modified as required to reflect chages i your fuctioal or cogitive abilities, social situatio, ad care service eeds. Policy Class meas persos who are isured by us uder this policy form with the same issue age, rate classificatio ad beefits similar to the beefits uder the policy. uch persos live i the same geographic area of the state as you did o the policy effective date. Qualified Log-Term Care ervices meas ecessary diagostic, prevetive, therapeutic, curig, treatig, mitigatig, ad rehabilitative services ad Maiteace or Persoal Care ervices which are required by a Chroically Ill perso. M26748_0809 9 Order Number: M26748_INIV_0809

Respite Care meas the supervisio ad care of you while the Family Members or other idividuals who ormally provide substatial amouts of upaid care o a daily basis take short-term leave or rest that provides them with temporary relief from the resposibilities of providig care. evere Cogitive Impairmet meas a loss or deterioratio i itellectual capacity that is comparable to ad icludes Alzheimer s disease ad similar forms of irreversible demetia; ad is measured by cliical evidece ad stadardized tests that reliably measure impairmet i your: (a) short-term or log-term memory; (b) orietatio as to people, places or time; (c) deductive or abstract reasoig; ad (d) judgmet as it relates to safety awareess. ubstatial Assistace meas either Hads-o Assistace or tadby Assistace. (a) Hads-o Assistace meas the physical assistace of aother perso without which you would be uable to perform the Activities of aily Livig. (b) tadby Assistace meas the presece of aother perso, withi your arm s reach, that is ecessary to prevet, by physical itervetio, ijury while you are performig the Activities of aily Livig. ubstatial upervisio meas cotiual supervisio (which may iclude cueig by verbal promptig, gestures or other demostratios) by aother perso that is ecessary to protect you from threats to your health or safety (icludig, but ot limited to, such threats as may result from waderig.) 10. LIMITATION AN EXCLUION We will ot pay beefits for: (a) services provided from a Family Member; (b) services for which o charge would be made i the absece of isurace; (c) for services provided outside of the Uited tates, its possessios or territories, Caada or the Uited Kigdom (except as provided i the INTERNATIONAL BENEFIT sectio of this policy); (d) services provided due to suicide (while sae or isae), attempted suicide or a itetioally self-iflicted ijury; (e) for treatmet of alcoholism or drug addictio (except for a addictio to a prescriptio medicatio whe admiistered i accordace with the advice of your Physicia); (f) for treatmet provided i a govermet facility uless we are required by law to cover the charges; (g) for treatmet of a ijury or sickess which would etitle you to beefits uder ay state or federal workers compesatio, employer s liability or occupatioal disease law, or ay motor vehicle o-fault law; (h) for services received while this policy is ot i force (except as provided i the Extesio of Beefits sectio); (i) services provided due to a act of declared or udeclared war. LIMITATION OR CONITION ON ELIGIBILITY OF BENEFIT Coditios Except as otherwise provided i the policy, you must icur eligible expeses for Qualified Log-Term Care ervices i order to receive beefits uder the policy. uch Qualified Log-Term Care ervices must be specified i a Pla of Care prepared for you by a Licesed Health Care Practitioer. Except for tay-at-home Beefits, if you are eligible for more tha oe type of beefit uder the policy o a sigle day, we will pay the beefit which pays the greater amout. atisfyig the Elimiatio Period Except as otherwise provided i the policy, we will ot pay beefits for eligible expeses icurred durig the Elimiatio Period. The Elimiatio Period commeces o the first day you are eligible for beefits uder the policy ad o which you: (a) are cofied to a Nursig Home or a Assisted Livig Facility; (b) receive Home Health Care or Adult ay Care; or (c) receive log-term care services covered uder the policy that are Medicare eligible (for which beefits are ot payable uder the policy). The Elimiatio Period must be satisfied oly oce durig the term of the policy. Maximum Lifetime Beefit Except as otherwise provided i the policy, ay beefits paid uder the policy will reduce the amout of your maximum lifetime beefit. No additioal beefits are payable uder the policy oce the maximum lifetime beefit has bee reduced to zero. No-uplicatio of Beefits We will ot pay beefits uder the policy to the extet that eligible expeses are reimbursable uder Medicare or other govermet program (except Medicaid) or would be so reimbursable except for the applicatio of a deductible or coisurace amout. M26748_0809 10 Order Number: M26748_INIV_0809

Coordiatio of Beefits Beefits uder the policy may be reduced if beefits for eligible expeses are paid by us or oe of our affiliates uder aother idividual log-term care isurace policy. Beefits will be reduced uder the policy oly whe paymet uder the policy ad such other log-term care isurace policy(ies) combied would exceed the actual amout you icur for eligible expeses. I o evet will we pay more uder this policy tha the differece betwee your actual eligible expeses ad the amout payable by such other log-term care isurace policy(ies). If you are isured uder oe or more policies without a similar Coordiatio of Beefits provisio, such policy(ies) will be deemed primary ad pay beefits first. The, paymet will be made uder ay policy without a similar Coordiatio of Beefits provisio i order of effective date, from the earliest to the latest. THE POLICY MAY NOT COVER ALL THE EXPENE AOCIATE WITH YOUR LONG-TERM CARE NEE. 11. RELATIONHIP OF COT OF CARE AN BENEFIT Because the costs of log-term care services will likely icrease over time, you should cosider whether ad how the beefits of this pla may be adjusted. You may elect oe of the iflatio protectio optios to icrease your coverage. Oly icreases take i accordace with oe of the iflatio protectio optios do ot require proof of isurability. 5% Compoud Iflatio Protectio (Lifetime) If you elect the optioal 5% Compoud Iflatio Protectio Beefit, o each policy aiversary date from ad after the compoud iflatio protectio startig date, we will automatically icrease the maximum mothly beefit the i effect uder the policy by 5%. I additio, o each policy aiversary date from ad after the compoud iflatio protectio startig date, we will automatically icrease the maximum lifetime beefit remaiig at the ed of the prior policy year by 5%. The icrease i the maximum mothly beefit ad the maximum lifetime beefit will be rouded to the earest whole dollar. I additio to 5% Compoud Iflatio Protectio (Lifetime) Beefit, as described above, you may select other percetages such as: 3% 4% 5% Compoud Iflatio Protectio 20 Year If you elect the optioal 5% Compoud Iflatio Protectio -20 Year Beefit, o each policy aiversary date up to ad icludig the 20 th policy aiversary date, we will automatically icrease each maximum mothly beefit the i effect uder the policy by 5%. O each policy aiversary date up to ad icludig the 20 th policy aiversary date, we will automatically icrease the maximum lifetime beefit remaiig at the ed of the prior policy year by 5%. The icrease i the maximum mothly beefit ad the maximum lifetime beefit will be rouded to the earest whole dollar. 5% imple Iflatio Protectio If you elect the optioal 5% imple Iflatio Protectio Beefit, o each policy aiversary date, we will automatically icrease the maximum mothly beefit the i effect uder the policy by a amout equal to the maximum mothly beefit i effect o the policy effective date multiplied by 5%. I additio, o each policy aiversary date, we will automatically icrease the maximum lifetime beefit remaiig at the ed of the prior policy year by a amout equal to the lesser of: (a) the maximum lifetime beefit i effect o the policy effective date multiplied by 5%; or (b) the maximum lifetime beefit remaiig at the ed of the prior policy year multiplied by 5%. The icrease i the maximum mothly beefit ad the maximum lifetime beefit will be rouded to the earest whole dollar. Future Purchase Optio If you elect this beefit, you may, upo writte request to us, purchase the Compoud Iflatio Protectio Lifetime Beefit rider for the policy, o or before the fifth policy aiversary date. You will be eligible to purchase the Compoud Iflatio Protectio Lifetime Beefit rider if, at the time of purchase: (a) we are ot waivig premium uder ay provisio of the policy; ad (b) you are ot Chroically Ill ad have ot for the immediate two-year period received beefits uder the policy. Purchase of Compoud Iflatio Protectio The Compoud Iflatio Protectio Lifetime Beefit rider will be effective o the policy aiversary date coicidig with or ext followig the date of your request. You may purchase the Compoud Iflatio Protectio Lifetime Beefit oly oce while the policy is i force. Your Premium Will Icrease We will icrease the premium for the policy if you purchase the Compoud Iflatio Protectio Lifetime Beefit rider. Premium will icrease by a amout determied by us at the time of your purchase. We will icrease the premium for the policy o the effective date of your purchase. However, ay icrease i beefits will NOT occur util the policy aiversary date followig the effective date of your purchase. M26748_0809 11 Order Number: M26748_INIV_0809

Iflatio Protectio Graphic Comparisos The chart to the left compares ad cotrasts the aticipated cost for oe year of istitutioal care of a 40-year period with the maximum lifetime beefit for three types of coverage: oe with 5% Compoud Iflatio Protectio (Lifetime); oe with 5% imple Iflatio (Lifetime); ad oe with o iflatio protectio at all. The chart assumes the isured starts with $64,605. The chart to the right compares the aual premium paid by a 63-year old perso for a policy with 5% Compoud Iflatio Protectio; 5% imple Iflatio Protectio; ad o iflatio protectio, assumig the followig coverage features: a 3-year beefit at $3000/moth ($3000 times 36 moths = $108,000 MLB); $3000/moth Nursig Home MMB; $3000/moth Assisted Livig Facility MMB; $3000/moth Home Health Care MMB; ad a Elimiatio Period of 90 days. $2,500 $2,000 $1,500 $1,000 $500 $0 Iflatio Protectio Aual Premium Illustratio $960 $1,6 13 No Iflatio 5% imple Iflatio (Lifetime) $2,0 35 5% Compoud Iflatio (Lifetime) M26748_0809 12 Order Number: M26748_INIV_0809

12. ALZHEIMER' IEAE AN OTHER ORGANIC BRAIN IORER Oce your applicatio for coverage uder the policy is approved, the policy provides coverage for treatmet of Alzheimer's disease, Parkiso's disease, seile demetia, ad all other forms of orgaic brai disease. 13. PREMIUM Refer to the table below to fid the aual premium. Premium Paymet Mode (Adjustmet Factor) PREMIUM Limited Pay - Complete below. Aual (1.0) emi-aual (.51) Quarterly (.26) Mothly Electroic Fuds Trasfer (.09) Basic Policy Coverage Premium: $ Noforfeiture Beefit horteed Beefit Period: $ 5% Compoud Iflatio Protectio: $ 3% Compoud Iflatio Protectio: $ 4% Compoud Iflatio Protectio: $ Future Purchase Optio: $ 5% Compoud Iflatio Protectio 20 Year: $ 5% imple Iflatio Protectio: $ Full Retur of Premium at eath Beefit: $ Retur of Premium at eath Less Claims Beefit: $ Retur of Premium at eath (Less Claims Paid) if eath occurs before Age 65 Beefit: $ Additioal Beefit for Ijury: $ Cash Beefit: $ pouse ecurity Beefit 60%: $ pouse hared Care Beefit: $ pouse Waiver of Premium Beefit: $ pouse urvivorship Beefit: $ Limited Pay - 10 Year Pay Optio: $ Limited Pay - 20 Year Pay Optio: $ Limited Pay - To Age 65 Pay Optio: $ igle Premium Paymet Optio: $ Waiver of Elimiatio Period for Home Health Care Beefit: $ Restoratio of Beefits: $ Total Aual Premium: $ Modal Premium: $ (Aual X Mode Factor) M26748_0809 13 Order Number: M26748_INIV_0809

14. AITIONAL FEATURE Uderwritig Medical uderwritig is required. We will uderwrite your applicatio by reviewig oe or more of the followig: the iformatio submitted o your applicatio; a attedig Physicia's report; copies of your medical records; a medical evaluatio; a telephoe iterview; ad a i-perso iterview. Extesio of Beefits If your policy lapses for opaymet of premium while you are cotiuously cofied i a Nursig Home or Assisted Livig Care Facility, beefits will be cotiued uder the policy. Protectio Agaist Uitetioal Lapse You have the right, at the time of applicatio, to desigate at least oe perso who is to receive otice of lapse or termiatio for opaymet of premiums i additio to yourself. You may chage this desigatio at ay time. To do so, you must otify us i writig. We will remid you i writig every two years of this opportuity. If the policy lapses due to opaymet of premiums because you were Chroically Ill, you may request, withi five moths of the date of lapse that we reistate this policy without requirig a applicatio. You must udergo a assessmet by a Licesed Health Care Practitioer ad obtai a certificatio that you became Chroically Ill o or before the date of lapse. Upo paymet of all past due premiums, the policy will be reistated as of the lapse date. 15. CONTACT THE TATE ENIOR HEALTH INURANCE AITANCE PROGRAM IF YOU HAVE GENERAL QUETION REGARING LONG-TERM CARE INURANCE. CONTACT THE INURANCE COMPANY IF YOU HAVE PECIFIC QUETION REGARING YOUR LONG-TERM CARE INURANCE POLICY. NOTICE: The Illiois eior Health Isurace Program (HIP) is available to aswer questios you might have. For iformatio o how you ca make use of the service, call or write: HIP 320 W. Washigto treet prigfield, Illiois 62767 1-800-548-9034 M26748_0809 14 Order Number: M26748_INIV_0809