4929L-1197 (Series 0798) -1- LA4929-CA_1102
Life Insurance Application
United of Omaha Life Insurance Company
■ ATTN: Life Agency: Mutual of Omaha Plaza, Omaha, NE 68175
■ ATTN: Life Brokerage: P.O. Box 2476, Omaha, NE 68103-2476
■ Life Insurance ■ Flexible Premium Variable Universal Life Insurance
■ Adult Life ■ Additional Insured Rider (AIR)
■ Juvenile Life ■ Specified Amount Increase
To The Agent/Broker:
■ Tear off the Notice of Exchange of Information, Summary of Rights Under the Fair Credit Reporting Act and give it to the
■ Have Authorization To Release Information on reverse side of this page signed and dated.
■ Assure that all applicable questions in Part I and Part II are answered in clear printed fashion.
■ Complete Nonmedical Supplement in all cases.
■ Be sure the application is signed by the Proposed Insured(s) and the Applicant if other than Proposed Insured(s).
■ Any changes should be initialed by the Proposed Insured(s) and, if applicable, the Applicant.
■ Use age last birthday.
■ Always provide the attached Temporary Life Insurance Agreement and Receipt when you accept a premium.
Premium Acceptance Guidelines:
Premium should only be accepted if:
(a) Questions 1, 2, 3 and 4 on the Temporary Life Insurance Agreement and Receipt form are answered “No.”
(b) The Temporary Life Insurance Agreement and Receipt form is signed, dated and witnessed by all parties indicated on
the form on the day the application is taken.
(c) A full modal premium is collected at the time of application unless the Bank Service Plan (BSP) is used, in which case
two BSP premiums should be collected.
(d) The total amount of insurance applied for does not exceed $500,000.