Please select your benefits

Protect your family. Enroll in Life Insurance Coverage Today

Voluntary Life Coverage Election – Children *

$10,000 (per child)

Decline

Voluntary AD&D Coverage Election – Child(ren) *

$10,000 (per child)

Decline

Beneficiary for Death Benefits – Primary Beneficiary Designation *

Address of Beneficiary (Address, City, State, Zip) *

Beneficiary for Death Benefits – Secondary Beneficiary Designation

Address of Secondary Beneficiary (Address, City, State, Zip)

I represent that the information I have provided in this enrollment form is complete, true and accurate to the best of my knowledge. I understand that payment of premium does not guarantee eligibility for coverage. I understand and agree that I must satisfy all active work or active eligibility requirements that pertain to the policy to be eligible for coverage. I understand and agree that life insurance coverage for my eligible dependent(s) may be delayed if they are confined (at home, in a hospital, or in any other institution or facility) or disabled on the date insurance would otherwise begin, in accordance with the terms of the policy. Should I apply for waived coverage in the future, I understand that evidence of insurability may be required, acceptable to the underwriting company, at my own expense. I understand that if coverage is applied for in the future, it must be during an enrollment period approved by the underwriting company or due to a life change event as defined or allowed by the applicable policy, and that a waiting period may apply. By signing below, I acknowledge that I understand and agree to the above statements, and that I have read and understand the benefit summary or outline of coverage provided to me for each type of coverage. The above requirements will apply unless otherwise stated in the applicable policy, or unless prohibited by any applicable state or federal law. *

I understand and agree

Signature *

United of Omaha Life Insurance Company
3300 Mutual of Omaha Plaza,
Omaha, Nebraska 68175

Enrollment Form

- You must elect coverage for yourself for your dependent(s) to be eligible.

- The benefit amount elected for your child(ren) cannot be more than 50% of your elected benefit amount.

- The benefit amount elected for your spouse cannot be more than 50% of your elected benefit amount.

- You must be age 70 or less for your spouse to be eligible for coverage. Spouse coverage terminates when you reach the age of 70.

- Your dependent child(ren) must be under age 26 to be eligible for insurance.

- You must elect coverage for yourself for your dependent(s) to be eligible.

- The benefit amount elected for your child(ren) cannot be more than 50% of your elected benefit amount.

- The benefit amount elected for your spouse cannot be more than 50% of your elected benefit amount.

- Your dependent child(ren) must be under age 26 to be eligible for insurance.

California Fraud Warning: For your protection, California law requires the following to appear on this form. Any person who knowingly presents a

false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement to state prison.