Mutual of Omaha Living Promise

Mutual of Omaha Living Promise

Mutual of Omaha Final Expense Application
Hassan Sanders
CEO/National Independent Agent
National Producer Number: 12878572

Toll-Free: (855) 468-8900
Direct: (773) 245-4080
Fax: (888) 806-1532

Email: info@DiabeticInsuranceSolutions.com
Website: www.DiabeticInsuranceSolutions.com
Name*

First NameLast Name
MaleFemale
Height*
Weight**
Home Street Address*
City in which you live in*
State in which you live in*
Zip Code*
State of Birth*
Date of Birth*

MonthDayYear
Date
Mobile Number*
Email*
Driver’s License No./State Issued ID and Expiration Date*
YesNo
YesNo
PART ONE:
IF THE PROPOSED INSURED ANSWERS “YES” TO ANY QUESTIONS IN PART ONE, THAT PERSON IS NOT ELIGIBLE FOR ANY COVERAGE UNDER THIS APPLICATION.
1. Is the Proposed Insured currently:
YesNo
YesNo
YesNo
2. Has the Proposed Insured ever been:
YesNo
YesNo
(b) diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig's Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure,Cirrhosis, Metastatic Cancer or Recurrent Cancer of the same type?*

YesNo
YesNo
YesNo
YesNo
3. In the past 12 months, has the Proposed Insured been:
YesNo
YesNo
4. In the past 2 years,
YesNo
PART TWO:
IF THE PROPOSED INSURED ANSWERS “YES” TO ANY QUESTION IN PART TWO, THAT PERSON IS ELIGIBLE ONLY FOR THE GRADED BENEFIT PRODUCT.
5. Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
YesNo
YesNo
YesNo
6. In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
YesNo
YesNo
YesNo
7. In the past 2 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health
YesNo
YesNo
8. In the past 2 years, has the Proposed Insured:
YesNo
YesNo
YesNo
9. In the past 2 years,
YesNo
10. In the past 12 months,
YesNo
List Of Medications and Dosages. (Put "n/a" if you aren't taking any medications)*
List ALL medication presecribed byyour doctor even if you aren't taking them anymore
Primary Care Physicians Name**
PLAN INFORMATION
Level Benefit (Day 1 Coverage)Graded Benefit Product (2 Yr Wait)
$5,000$6,000$7,000$8,000$9,000$10,000$15,000$20,000$25,000$30,000$35,000$40,000
AnnualMonthly (Checking Account Required)
Beneficiary
Primary Beneficiary*
Percentage*
(For Example: Jane Doe 100% of death benefit)
Primary Beneficiary Date of Birth*

MonthDayYear
Date
OTHER COVERAGE INFORMATION
YesNo
YesNo
If “Yes” to questions #1 or #2, please give details below. If more space is needed, list below. Please Provide Company and Face amount and if it will be replaced.
PAYMENT
Initial Premium Payment (Type "IMMEDIATELY" below or pick a Due Date between days 1-28)*
Payer Information (Name as it appears on bank account)*
CheckingSavings
Signature of Proposed Insured*

Clear
I verify and confirm that my answers to the health questions are try and correct
Please verify that you are human*
Should be Empty: