Long-Term Disability

Long-Term Disability

Premium Quote

Presented by:

Home Office

none

402-351-0000

Prepared for:

DI AS AN INCOME PROTECTOR

Disability Insurance Choice Portfolio

WORKS

Premium Premium Includes Annual Premium Monthly Disability Benefit $3,500 (Includes total of Base Disability Benefit and SIS Rider)

Base Disability Benefit $1,500 per month $ 743.96 Social Insurance Supplement Rider $2,000 per month $ 587.51

Waiver of Premium No Cost

Total Premium After Savings if Applied

Monthly BSP (Bank Service Plan) Premium $120.89

Quarterly Premium $359.18

Semi-Annual Premium $711.46

Annual Premium $1,381.47

(Premium includes policy Fee) (*Premium savings does not apply to this rider or policy fee) Note: There is an additional cost for premium payments made more frequently than once a year.

Available Premium Savings

You’ve taken the first step toward protecting your family’s income. Now share the news with your co-workers and save an additional 15% off your current premiums by qualifying for the Common Employer discount. Ask your Producer for details.

The total potential maximum benefit assuming payment of the full monthly benefit for the entire benefit period is $882,000. Policy

Summary

Long-Term Disability - This policy pays the insured a monthly cash benefit of $1,500 for up to age 67 as long as they are totally disabled and unable to work because of a covered accident or sickness. Benefits begin after 90 days of a period of disability. This policy is guaranteed renewable to the insured's age 67. After the insured has attained the age of 67, the policy may continue to renew until the first policy renewal following the insured's 75th birthday providing the insured is working full-time.

This is a premium quote for a Long-Term Disability policy, not an offer, and is subject to regular underwriting. Please refer to the Summary/Outline of coverage for more details, including information regarding exceptions, limitations, and reductions of your coverage.

Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175 Presented by: Mutual of Omaha - Home Office License Number: none Date: 07/21/2015 Version: 1.71 Policy Form: D81 Page: 2 of 7

Premium Quote

NE Age: 45 / Male / Non-Tobacco User / ST Benefit Period: To Age 67

Occupation Class: 4A Elimination Period: 90 Days

PROVISIONS

Total Disability During the 90 day elimination period and during the first 24 months following the elimination period, total disability due to sickness or injury means that the insured is unable to perform the material and substantial duties of their regular occupation; is not engaged in any occupation for wage or profit; is under the regular medical care of a physician.

After the first 24 months following the elimination period, total disability due to sickness or injury means that the insured: 1) is unable to perform the material and substantial duties of any occupation which they are reasonably suited by means of education, training or experience; and 2) is under the regular medical care of a physician.

Presumptive Total Disability

The insured will be presumed totally disabled and the normal total disability requirements will be waived if they incur any of the following uncorrectable losses due to sickness or injury:

· Speech

· Hearing in both ears · Sight in both eyes

· The use of both hands, both feet or one hand and one foot

Benefits are payable at 100% of the Total Disability Monthly Benefit and the elimination period is waived. The Insured's ability to work will not affect the benefits and proof of further medical treatment will not be required.

Proportionate Disability

After the 90 day elimination period and during the first 24 months following the elimination period, proportional disability due to sickness or injury means that the insured: 1) is unable to perform one or more of the material and substantial duties of their regular occupation; 2) has experienced a loss of monthly income of at least 20%, but not more than 80% of their prior monthly income; and 3) is under the regular medical care of a physician.

Proportionate Disability benefits begin after the Elimination Period has been satisfied. Benefits are payable while you remain Proportionately Disabled for:

Waiver of Premium Waiver of Premium pays the premium when the insured meets the definition of total disability, partial disability, or presumptive total disability. Premium is waived after 90 days of disability until the end of the benefit period. There is no additional cost for this benefit.

Exclusions and Limitations

Benefits are not payable for:

(a) loss that begins while this policy is not in force;

(b) loss resulting from an act of declared or undeclared war;

(c) loss sustained while serving in the armed forces (upon notice to us of entry into the armed forces, the unearned portion of the premium will be refunded);

(d) loss caused by intentionally self-inflicted injury;

(e) loss resulting from commission or attempted commission of a felony; (f) loss caused by suicide or attempted suicide, while sane or insane; or (g) loss resulting from your being legally intoxicated or under the influence

of an illegal substance or a narcotic (except for narcotics given on the advice of and taken as prescribed by a Physician).

Pregnancy: Benefits are not payable for loss due to Normal childbirth, Normal Pregnancy or voluntarily induced abortion. We will pay benefits for Complications of Pregnancy on the same basis as any other Sickness.

Exclusions and Limitations are different in CA, CT, NV, NY, PA, SD, VT and WA.

Please ask your producer for an Outline.

Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175

Presented by: Mutual of Omaha - Home Office Date: 07/21/2015

Version: 1.71 Policy Form: D81 Page: 4 of 7

Premium Quote

Age:

Benefit Period:

Occupation Class:

Elimination Period:

BENEFITS AND RIDERS

Social Insurance Supplement Rider

Following the elimination period, the insured's Social Insurance Supplement (SIS) monthly benefit will be paid for Total Disability.

The SIS monthly benefit of $2,000 will be reduced by the amount of Social Insurance benefits, if any, for the loss being claimed. In the event of a future increase in the amount of Social Insurance benefits payable, the SIS monthly benefit will not be further reduced by the amount of such increase. Social Insurance benefits include the following:

· Social Security Disability Benefits · Workers Compensation

MEDICAL UNDERWRITING GUIDELINES

MEDICAL UNDERWRITING GUIDELINES

Short-Term Disability – D82 Accident Only Disability – D83

Long-Term Plan Total Monthly Benefit Amount Accident Only Disability Short-Term Disability 2-Year and 5-Year Benefit Period 10-Year and To Age 67 Benefit Period Business Operating Expense $300-$3,000 Simplified Underwriting1 Simplified Underwriting1 _Interview Interview Simplified Underwriting1 $3,100-$5,000 Interview Interview, Physical Data, Blood and Urine

Interview

$5,100-$8,000 Interview,

Physical Data, Blood and Urine

Interview, Long Form Paramed, Blood and Urine

Interview, Physical Data, Blood and Urine $8,100 and Above Interview, Long Form Paramed, Blood and Urine,

EKG2

Interview, Long Form Paramed, Blood and Urine,

EKG2

Interview, Long Form Paramed,

Blood and Urine, EKG2

1_{Underwriting decisions within 48 hours of initial underwriting review provided the following conditions are met:}

Applicant is in occupation class 6A, 5A, 4A, 3A, or 2A 

For Accident Only Disability coverage: Applicant is age 55 or younger and medically standard 

For Short-Term and Long-Term Disability coverage: Applicant is nontobacco, age 45 or younger, and medically standard 

No adverse information from the Medical Information Bureau 

All application questions have been clearly and completely answered and required forms and financial documents have 

been submitted with the application

2_{Age 45 and over only}

Underwritten by Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska 68175

Presented by: Mutual of Omaha - Home Office Date: 07/21/2015

Version: 1.71 Policy Form: D81 Page: 6 of 7

Premium Quote

Proposed Insured:

State of Issue:

Age:

Benefit Period:

Financial Underwriting Guidelines

Income Documentation

The last two years taxes are required for individuals applying for the employed preferential rates. If you qualify for the self-employed discount, you will also be eligible for the automatic income increase of up to 20%, which can provide up to an additional $1000 in monthly benefit.

Individuals who have been self-employed less than 12 months but are engaged in the same occupation or line of work as previously employed (W-2) may be eligible for up to 50% of prior two years W-2 earnings. Newly Self-Employed eligibility requirements are listed in the underwriting Guidelines.

Premium Quote

Occupation Class: 4A Elimination Period: 90 Days

Proposed Insured: DI AS AN INCOME PROTECTOR State of Issue: NE Age: 45 / Male / Non-Tobacco User / ST Benefit Period: To Age 67

When it comes to Disability Insurance, there is not a one-size-fits-all solution. At Mutual of Omaha, we have tools to design a policy that fits your unique needs.

Your lifestyle and dreams for your future depend on your ability to work and earn an income, we can help you protect it. Review the benefit options above to help you choose the right protection for you with a price that fits your budget.

ACCIDENT ONLY DISABILITY

2-Year Benefit Period 14-Day Elimination Period Max Income Replacement

Total/Partial Disability Presumptive Total Disability Survivor

Waiver of Premium Recurrent Disability

Workers‒ Compensation Rider

Premium: $448.54

Premium: $1716.86

Premium: $1053.87

Premium: $671.74

Each policy option comes with these benefits: Total/Partial Disability, Presumptive Total Disability, Proportionate Disability, Transplant Donor, Terminal Illness, Survivor, Rehabilitation, Waiver of Premium, Recurrent Disability and Workers‒ Compensation Rider. By choosing from these three options you will be provided with the coverage you need to secure the life you have built.

T67-Year Benefit Period 90-Day Elimination Period Max Income Replacement Extended Own OCC Rider Social Insurance

Supplement Rider Extended Proportionate Rider

5-Year Benefit Period 90-Day Elimination Period Max Income Replacement Extended Proportionate Social Insurance

Supplement Rider 5-Year Benefit Period

Client Name DI AS AN INCOME PROTECTOR

Sex Male

Age Last Birthday 45

Tobacco User

Student Program No

Risk Class Standard

Is client a Railroad Employee? No

Is client a Government Employee? No

Main Occupation Category None

Main Occupation Category Job Description

Job Description

Occupation Class 4A

Annual Earned Income 61128

State Code NE

State Disability Eligibility State Disability Amount

Are you covered under CalSTRS or CalPERS?

Self-Employed Savings - Financials Required No Assocation Member Savings

Common Employer Savings Life/DI Savings

Benefit Period To Age 67

Elimination Period 90 Days

Premium and Benefit Options

Premium Mode Annual

Premium Mode

Type Maximum Benefit

Is coverage to be puchased taxed? No

Group LTD No

Case: untitled.recovered Client #1 Premium and Benefit Options - Cont'd

Total Monthly Benefit

Total Monthly Benefit Amount Total Monthly Benefit Percentage

Social Insurance Supplement Yes

Minimum SIS Benefit

Maximize SIS Benefit Yes

Specify SIS Benefit SIS Benefit Amount

** Premium Result ** 1381.47

Riders

Cost of Living Adjustment No

Extended Own-Occ Disability No

Extended Proportionate Rider No

Future Insurability Option No

Critical Illness No

Critical Illness Benefit Amount

Hospital Confinement Indemnity No

Daily Room & Board Benefit Amount

Return of Premium Rider No

Percentage

Accident Medical Expense Rider No

Accident Medical Expense Benefit Amount

Monthly Expenses

Total Monthly Expense Only Ownership Percentage Total Monthly Expense Employee Salaries Interest on Loans

Mortgage Interest Payments Insurance [casualty/liability] Property Taxes [real and personal] Depreciation [office equipment only] Rent [including land rental]

Electricity Heat Water Telephone

Postage and Stationery Equipment Rental

Other Fixed Operating Expenses

Optional Pages

Print Values Page No

Alternate Premiums No

Good, Better, Best Yes

Home Office

For Home Office Use Only No

Producer Info

Producer Name Home Office

Producer License Number