NAP22_MN 06/14/2017

APPLICATION for MEDICARE SUPPLEMENT INSURANCE

________________________________________________________________________

MINNESOTA

CP15

.D-M

N

OM

AH

A IN

SUR

AN

CE

CO

MPA

NY

OM

AH

A, N

EBR

ASK

AOU

TLIN

E OF

MED

ICAR

E SU

PPLE

MENT

COV

ERAG

E – C

OVER

PAG

E

BASI

C AN

D EX

TEND

ED B

ASIC

PLA

NSTh

e Com

miss

ioner

of In

sura

nce o

f the S

tate o

f Minn

esota

has e

stabli

shed

two c

atego

ries o

f Med

icare

Sup

pleme

nts an

d mini

mum

stand

ards

for e

ach,

with

theex

tende

d bas

ic Me

dicar

e Sup

pleme

nt be

ing th

e mos

t com

preh

ensiv

e and

the b

asic

Medic

are S

upple

ment

being

the l

east

comp

rehe

nsive

.Th

is ch

art s

hows

the

bene

fits in

each

plan

.

Basic

--Pol

icy F

orm

NM2

6Ho

spita

lizati

on: P

art A

Coin

sura

nce

Medic

al Ex

pens

es: P

art B

Coin

sura

nce

Bloo

d: Fir

st 3 p

ints o

f bloo

d eac

h yea

r

Skille

d Nur

sing C

oinsu

ranc

e

____

____

____

____

____

____

*

____

____

____

____

____

____

*

____

____

____

____

____

____

*

Fore

ign T

rave

l Eme

rgen

cy

Hosp

ice C

are

____

____

____

____

____

____

*

Exte

nded

Bas

ic--P

olicy

For

m N

M27

Hosp

italiz

ation

: Par

t A C

oinsu

ranc

e

Medic

al Ex

pens

es: P

art B

Coin

sura

nce

Bloo

d: Fir

st 3 p

ints o

f bloo

d eac

h yea

r

Skille

d Nur

sing C

oinsu

ranc

e

Part

A De

ducti

ble

Part

B De

ducti

ble

Part

B Ex

cess

(100

%)

Fore

ign T

rave

l Eme

rgen

cy

Hosp

ice C

are

Prev

entiv

e Car

e

PREM

IUM

INFO

RMAT

ION

We,

Omah

a Ins

uran

ce C

ompa

ny, w

ill re

new

the po

licy e

ach t

ime y

ou pa

y us t

he pr

emium

.It m

ust b

e by t

he da

te it i

s due

or du

ring t

he 31

days

that

follow

.You

rpo

licy s

tays i

n for

ce du

ring t

his 31

-day

perio

d.Yo

ur pr

emium

cann

ot be

chan

ged u

nless

we m

ake t

he sa

me ch

ange

on al

l poli

cies o

f this

form

owne

d by p

erso

ns in

your

clas

sifica

tion w

hich a

re re

newe

d in t

he st

ate w

here

you l

ive at

the t

ime w

e cha

nge t

he pr

emium

.An

y suc

h cha

nge c

an be

mad

e on a

ny re

newa

l date

.We w

illgiv

e you

30 da

ys ad

vanc

e writt

en no

tice r

equir

ed by

your

state

prior

to an

y pre

mium

chan

ge.

Sche

dules

of ra

tes m

ay va

ry de

pend

ing on

your

Poli

cy D

ate.

"Per

sons

in Y

our C

lassif

icatio

n" m

eans

all p

erso

ns ha

ving t

he sa

me be

nefits

.

“Per

sons

in Y

our C

lassif

icatio

n” m

eans

all p

erso

ns ha

ving t

he sa

me be

nefits

.

*Opti

onal

rider

s ava

ilable

for P

art A

Ded

uctib

le, P

art B

Exc

ess,

Medic

are P

art B

Ded

uctib

le an

d Pre

venti

ve H

ealth

Ser

vices

.

1

RP1

5.9.

D-M

N

OM

AH

A IN

SUR

AN

CE

CO

MPA

NY

OM

AH

A, N

EB

RA

SKA

MO

NT

HL

Y P

RE

MIU

MS

ZIP

CO

DE

S:55

002,

550

06-0

09, 5

5012

-013

, 550

17-0

19, 5

5021

, 550

26-0

27, 5

5029

-030

, 550

32, 5

5036

-037

, 550

40-0

41, 5

5045

-046

, 550

49,

5505

1-05

3, 5

5056

-057

, 550

60, 5

5063

, 550

66-0

67, 5

5069

, 550

72, 5

5074

, 550

78-0

80, 5

5084

, 550

87-0

89, 5

5092

, 553

01-3

02, 5

5307

-310

, 553

12-

314,

553

19-3

21, 5

5324

-325

, 553

28-3

30, 5

5332

-336

, 553

38, 5

5341

-342

, 553

49-3

50, 5

5353

-355

, 553

58, 5

5362

-363

, 553

65-3

66, 5

5370

-553

71

NO

N-T

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

ST

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

S

Bas

ic—

Polic

y Fo

rmN

M26

All

Age

s$

144.

51B

asic

—Po

licy

Form

NM

26A

ll A

ges

$16

6.11

Opt

iona

l Rid

ers

Opt

iona

l Rid

ers

Part

A D

educ

tible

Rid

er0N

R3F

$23

.83

Part

A D

educ

tible

Rid

er0N

R3F

$27

.39

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

4.43

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

5.09

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$34

5.73

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$39

7.39

To o

btai

n an

nual

, sem

iann

ual,

and

quar

terly

pre

miu

ms,

mul

tiply

the

abov

e-qu

oted

pre

miu

ms b

y 12

, 6, a

nd 3

, res

pect

ivel

y.

The

polic

y pr

ovid

es a

n an

ticip

ated

loss

ratio

of 7

6%. T

his m

eans

that

, on

aver

age,

Pol

icyh

olde

rs m

ay e

xpec

t tha

t $76

.00

of e

very

$10

0.00

inpr

emiu

m w

ill b

e re

turn

ed a

s ben

efits

to th

e Po

licyh

olde

rs o

ver t

he li

fe o

f the

con

tract

.

RP1

5.9.

D-M

N

OM

AH

A IN

SUR

AN

CE

CO

MPA

NY

OM

AH

A, N

EB

RA

SKA

MO

NT

HL

Y P

RE

MIU

MS

ZIP

CO

DE

S:55

373,

553

76-3

77, 5

5380

-382

, 553

85, 5

5389

-390

, 553

93, 5

5395

-396

, 553

98, 5

56-5

67

NO

N-T

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

ST

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

S

Bas

ic—

Polic

y Fo

rmN

M26

All

Age

s$

144.

51B

asic

—Po

licy

Form

NM

26A

ll A

ges

$16

6.11

Opt

iona

l Rid

ers

Opt

iona

l Rid

ers

Part

A D

educ

tible

Rid

er0N

R3F

$23

.83

Part

A D

educ

tible

Rid

er0N

R3F

$27

.39

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

4.43

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

5.09

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$34

5.73

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$39

7.39

To o

btai

n an

nual

, sem

iann

ual,

and

quar

terly

pre

miu

ms,

mul

tiply

the

abov

e-qu

oted

pre

miu

ms b

y 12

, 6, a

nd 3

, res

pect

ivel

y.

The

polic

y pr

ovid

es a

n an

ticip

ated

loss

ratio

of 7

6%. T

his m

eans

that

, on

aver

age,

Pol

icyh

olde

rs m

ay e

xpec

t tha

t $76

.00

of e

very

$10

0.00

inpr

emiu

m w

ill b

e re

turn

ed a

s ben

efits

to th

e Po

licyh

olde

rs o

ver t

he li

fe o

f the

con

tract

.

RP1

5.9.

D-M

N

OM

AH

A IN

SUR

AN

CE

CO

MPA

NY

OM

AH

A, N

EB

RA

SKA

MO

NT

HL

Y P

RE

MIU

MS

ZIP

CO

DE

S:55

001,

550

03, 5

5010

, 550

16, 5

5020

, 550

24-0

25, 5

5031

, 550

33, 5

5038

, 550

42-0

44, 5

5047

, 550

54-0

55, 5

5065

, 550

68, 5

5071

, 550

73,

5507

5-07

7, 5

5082

-083

, 550

85, 5

5090

, 551

18, 5

5120

-125

, 551

28-1

29, 5

5150

, 553

06, 5

5315

, 553

17-3

18, 5

5322

, 553

37, 5

5339

, 553

52, 5

5360

,55

367-

368,

553

72, 5

5378

-379

, 553

83, 5

5386

-388

, 553

94, 5

5397

, 553

99, 5

5473

NO

N-T

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

ST

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

S

Bas

ic—

Polic

y Fo

rmN

M26

All

Age

s$

155.

22B

asic

—Po

licy

Form

NM

26A

ll A

ges

$17

8.41

Opt

iona

l Rid

ers

Opt

iona

l Rid

ers

Part

A D

educ

tible

Rid

er0N

R3F

$23

.83

Part

A D

educ

tible

Rid

er0N

R3F

$27

.39

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

4.43

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

5.09

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$37

1.34

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$42

6.82

To o

btai

n an

nual

, sem

iann

ual,

and

quar

terly

pre

miu

ms,

mul

tiply

the

abov

e-qu

oted

pre

miu

ms b

y 12

, 6, a

nd 3

, res

pect

ivel

y.

The

polic

y pr

ovid

es a

n an

ticip

ated

loss

ratio

of 7

6%. T

his m

eans

that

, on

aver

age,

Pol

icyh

olde

rs m

ay e

xpec

t tha

t $76

.00

of e

very

$10

0.00

inpr

emiu

m w

ill b

e re

turn

ed a

s ben

efits

to th

e Po

licyh

olde

rs o

ver t

he li

fe o

f the

con

tract

.

RP1

5.9.

D-M

N

OM

AH

A IN

SUR

AN

CE

CO

MPA

NY

OM

AH

A, N

EB

RA

SKA

MO

NT

HL

Y P

RE

MIU

MS

ZIP

CO

DE

S:55

005,

550

11, 5

5014

, 550

70, 5

5101

-117

, 551

19, 5

5126

-127

, 551

30, 5

5133

, 551

44-1

46, 5

5155

, 551

61, 5

5164

-166

, 551

68-1

72,

5517

5, 5

5177

, 551

82, 5

5187

-188

, 553

03-3

05, 5

5311

, 553

16, 5

5323

, 553

27, 5

5331

, 553

40, 5

5343

-348

, 553

56-3

57, 5

5359

, 553

61, 5

5364

, 553

69,

5537

4-37

5, 5

5384

, 553

91-3

92, 5

5401

-450

, 554

54-4

55, 5

5458

-460

, 554

67-4

68, 5

5470

, 554

72, 5

5474

, 554

78-4

80, 5

5487

-488

NO

N-T

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

ST

OB

AC

CO

—M

ON

TH

LY

PR

EM

IUM

S

Bas

ic—

Polic

y Fo

rmN

M26

All

Age

s$

167.

71B

asic

—Po

licy

Form

NM

26A

ll A

ges

$19

2.77

Opt

iona

l Rid

ers

Opt

iona

l Rid

ers

Part

A D

educ

tible

Rid

er0N

R3F

$23

.83

Part

A D

educ

tible

Rid

er0N

R3F

$27

.39

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

4.43

Prev

enta

tive

Med

ical

Car

e R

ider

0NR

5F$

5.09

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B E

xces

s Rid

er0N

R6F

$-

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Part

B D

educ

tible

Rid

er0N

R4F

$15

.21

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$40

1.21

Ext

ende

d B

asic

—Po

licy

Form

NM

27A

ll A

ges

$46

1.16

To o

btai

n an

nual

, sem

iann

ual,

and

quar

terly

pre

miu

ms,

mul

tiply

the

abov

e-qu

oted

pre

miu

ms b

y 12

, 6, a

nd 3

, res

pect

ivel

y.

The

polic

y pr

ovid

es a

n an

ticip

ated

loss

ratio

of 7

6%. T

his m

eans

that

, on

aver

age,

Pol

icyh

olde

rs m

ay e

xpec

t tha

t $76

.00

of e

very

$10

0.00

inpr

emiu

m w

ill b

e re

turn

ed a

s ben

efits

to th

e Po

licyh

olde

rs o

ver t

he li

fe o

f the

con

tract

.

DP

1D-M

N

DIS

CLO

SUR

ESU

se th

is o

utlin

e to

com

pare

ben

efits

and

pre

miu

ms

amon

g po

licie

s.

REA

D Y

OU

R P

OLI

CY

VER

Y C

AR

EFU

LLY

This

is o

nly

an o

utlin

e de

scrib

ing

your

pol

icy'

s m

ost

impo

rtant

feat

ures

.Th

e po

licy

is y

our i

nsur

ance

cont

ract

.Y

ou m

ust r

ead

the

polic

y its

elf t

o un

ders

tand

all o

f the

righ

ts a

nd d

utie

s of

bot

h yo

u an

d yo

urin

sura

nce

com

pany

.

RIG

HT

TO R

ETU

RN

PO

LIC

YIf

you

find

that

you

are

not

sat

isfie

d w

ith y

our p

olic

y, y

oum

ay re

turn

it to

Om

aha

Insu

ranc

e C

ompa

ny, M

utua

l of

Om

aha

Pla

za, O

mah

a, N

E 6

8175

.If

you

send

the

polic

yba

ck to

us

with

in 3

0 da

ys a

fter y

ou re

ceiv

e it,

we

will

treat

the

polic

y as

if it

had

nev

er b

een

issu

ed a

nd re

turn

all o

f you

r pay

men

ts, w

ithin

10

days

.

POLI

CY

REP

LAC

EMEN

TIf

you

are

repl

acin

g an

othe

r hea

lth in

sura

nce

polic

y, d

oN

OT

canc

el it

unt

il yo

u ha

ve a

ctua

lly re

ceiv

ed y

our n

ewpo

licy

and

are

sure

you

wan

t to

keep

it.

NO

TIC

ETh

e po

licy

may

not

fully

cov

er a

ll of

you

r med

ical

cos

ts.

Nei

ther

Om

aha

Insu

ranc

e C

ompa

ny n

or it

s ag

ents

are

conn

ecte

d w

ith M

edic

are.

This

out

line

of c

over

age

does

not g

ive

all t

he d

etai

ls o

f Med

icar

e co

vera

ge.

Con

tact

your

loca

l Soc

ial S

ecur

ity o

ffice

or c

onsu

lt "M

edic

are

&Y

ou" f

or m

ore

deta

ils.

CO

MPL

ETE

AN

SWER

S A

RE

VER

Y IM

POR

TAN

TR

evie

w th

e ap

plic

atio

n ca

refu

lly b

efor

e yo

u si

gn it

.B

e ce

rtain

that

all

info

rmat

ion

has

been

pro

perly

reco

rded

.

THE

PO

LIC

Y D

OE

S N

OT

CO

VE

R A

LL M

ED

ICA

L E

XP

EN

SE

SB

EY

ON

D T

HO

SE

CO

VE

RE

D B

Y M

ED

ICA

RE

.TH

E P

OLI

CY

DO

ES

NO

T C

OV

ER

ALL

SK

ILLE

D N

UR

SIN

G H

OM

E C

AR

EE

XP

EN

SE

S A

ND

DO

ES

NO

T C

OV

ER

CU

STO

DIA

L O

RR

ES

IDE

NTI

AL

NU

RS

ING

CA

RE

.R

EA

D Y

OU

R P

OLI

CY

CA

RE

FULL

Y T

O D

ETE

RM

INE

WH

ICH

NU

RS

ING

HO

ME

FAC

ILIT

IES

AN

D E

XP

EN

SE

S A

RE

CO

VE

RE

D B

Y Y

OU

RP

OLI

CY

.

We

will

not p

ay fo

r ser

vice

s fo

r whi

ch a

cha

rge

is n

orm

ally

not

mad

e w

here

ther

e is

no

insu

ranc

e.In

add

ition

, no

bene

fits

are

paya

ble

for e

xpen

se in

curr

ed b

efor

e th

e co

vera

ge e

ffect

ive

date

.

LIM

ITA

TIO

N O

N O

UT-

OF-

POC

KET

EXP

ENSE

Whe

n yo

ur o

ut-o

f-poc

ket e

xpen

se e

qual

s $1

,000

.00

in a

cale

ndar

yea

r, w

e w

ill pa

y 10

0% o

f add

ition

al c

over

ed e

xpen

seyo

u in

cur d

urin

g th

e re

mai

nder

of s

uch

cale

ndar

yea

r (N

M27

only

).

6

BC

15.D

-MN

BASI

C PL

AN -

NM26

MEDI

CARE

(PAR

T A)

- HO

SPIT

AL S

ERVI

CES

- PER

BEN

EFIT

PER

IOD

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of th

e hos

pital

and h

ave n

ot re

ceive

dsk

illed c

are i

n any

othe

r fac

ility f

or 60

days

in a

row.

Servi

ces

Medic

are P

ays

Plan

NM2

6 Pay

sYo

u Pay

HOSP

ITAL

IZAT

ION*

Semi

priva

te ro

om an

d boa

rd, g

ener

alnu

rsing

and m

iscell

aneo

us se

rvice

san

d sup

plies

First

60 da

ysAl

l but

$1,31

6$0 $1

,316 w

ith O

ption

al Pa

rt A

Dedu

ctible

Bene

fit Ri

der 0

MJ1W

$1,31

6 (Pa

rt A

Dedu

ctible

)

$0

61st t

hrou

gh 90

th day

All b

ut $3

29 a

day

$329

a da

y$0

91st d

ay an

d afte

r:W

hile u

sing 6

0 life

time

rese

rve da

ysAl

l but

$658

a da

y$6

58 a

day

$0

Beyo

nd th

e add

itiona

l 150

days

$010

0% of

Med

icare

Eligi

ble E

xpen

ses

$0

SKILL

ED N

URSI

NG F

ACILI

TY C

ARE*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a hos

pital

for at

leas

t 3 da

ys an

den

tered

a Me

dicar

e app

rove

d fac

ility

withi

n 30 d

ays a

fter le

aving

the

hosp

ital. Fir

st 20

days

All a

ppro

ved a

moun

ts$0

$0

21st t

hrou

gh 10

0th day

All b

ut $1

64.50

a da

yUp

to $1

64.50

a da

y$0

101st d

ay an

d afte

r$0

$0Al

l cos

tsBL

OOD

First

3 pint

s$0

3 pint

s$0

Addit

ional

amou

nts10

0%$0

$0HO

SPIC

E CA

REYo

u mus

t mee

t Med

icare

'sre

quire

ments

, inclu

ding a

docto

r'sce

rtifica

tion o

f term

inal il

lness

.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce f

or ou

tpatie

ntdr

ugs a

nd in

patie

nt re

spite

care

Medic

are c

opay

ment/

coins

uran

ce$0

7

BC

15.D

-MN

BASI

C PL

AN -

NM26

MEDI

CARE

(PAR

T B)

- ME

DICA

L SER

VICE

S - P

ER C

ALEN

DAR

YEAR

Servi

ces

Medic

are P

ays

Plan

NM2

6 Pay

sYo

u Pay

MEDI

CAL

EXPE

NSES

—IN

OR

OUT

OF T

HEHO

SPIT

AL A

ND O

UTPA

TIEN

T HO

SPIT

ALTR

EATM

ENT,

such

as ph

ysici

an’s

servi

ces,

inpati

ent a

nd ou

tpatie

nt me

dical

and s

urgic

alse

rvice

s and

supp

lies,

phys

ical a

nd sp

eech

thera

py, d

iagno

stic t

ests,

dura

ble m

edica

leq

uipme

nt First

$183

of M

edica

re A

ppro

ved

Amou

nts**

$0$0 $1

83 w

ith O

ption

al Be

nefit

Ride

r0M

J2W

$183

(Par

t B D

educ

tible)

$0

Rema

inder

of M

edica

re A

ppro

ved

Amou

nts80

%20

%***

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

reAp

prov

ed A

moun

ts)$0

$0 100%

with

Ride

r 0MJ

4W

All c

osts

$0BL

OOD

First

3 pint

s$0

All c

osts

$0Ne

xt $1

83 of

Med

icare

App

rove

dAm

ounts

*$0

$0 $183

with

Opti

onal

Bene

fit Ri

der

0MJ2

W

$183

(Par

t B D

educ

tible)

$0

Rema

inder

of M

edica

re A

ppro

ved

Amou

nts80

%20

%$0

CLIN

ICAL

LAB

ORAT

ORY

SERV

ICES

—TE

STS

FOR

DIAG

NOST

IC S

ERVI

CES

100%

$0$0

*Onc

e you

have

been

bille

d $18

3 of M

edica

re A

ppro

ved A

moun

ts for

cove

red s

ervic

es, y

our P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

.**O

nce y

ou ha

ve be

en bi

lled $

183 o

f Med

icare

App

rove

d Amo

unts

for co

vere

d ser

vices

, you

r Par

t B D

educ

tible

will h

ave b

een m

et for

the c

alend

ar ye

ar.

***Pa

rt B

coins

uran

ce (g

ener

ally 2

0% of

Med

icare

appr

oved

expe

nses

), or

in th

e cas

e of h

ospit

al ou

tpatie

nt de

partm

ent s

ervic

es un

der a

pros

pecti

ve pa

ymen

tsy

stem,

appli

cable

copa

ymen

ts.

8

BC

15.D

-MN

BASI

C PL

AN -

NM26

PART

S A

AND

B

Servi

ces

Medic

are P

ays

Plan

NM2

6 Pay

sYo

u Pay

HOME

HEA

LTH

CARE

—ME

DICA

RE A

PPRO

VED

SERV

ICES

Medic

ally n

eces

sary

skille

d car

e ser

vices

and m

edica

l sup

plies

100%

$0$0

Dura

ble m

edica

l equ

ipmen

tFir

st $1

83 of

Med

icare

App

rove

d Amo

unts*

$0$0 $1

83 w

ith O

ption

al Be

nefit

Ride

r 0MJ

2W

$183

(Par

t B D

educ

tible)

$0

Rema

inder

of M

edica

re A

ppro

ved

Amou

nts80

%20

%$0

OTHE

R BE

NEFI

TS –

NOT

COVE

RED

BY M

EDIC

ARE

FORE

IGN

TRAV

EL—

NOT

COVE

RED

BY M

EDIC

ARE

Medic

ally n

eces

sary

emer

genc

y car

e ser

vices

begin

ning d

uring

trav

elou

tside

the U

SA (h

ospit

al, m

edica

l exp

ense

and s

uppli

es)

$080

% of

cove

red e

xpen

ses

Expe

nses

not p

aid by

Medic

are o

r the

polic

yPR

EVEN

TIVE

MED

ICAL

CAR

E BE

NEFI

T--

NOT

COVE

RED

BY M

EDIC

ARE

Annu

al ph

ysica

l and

prev

entiv

e tes

ts an

d ser

vices

admi

nister

ed or

orde

red b

y you

r doc

tor w

hen n

ot co

vere

d by M

edica

re.

First

$120

each

calen

dar y

ear

Addit

ional

Char

ges

$0 $0

$0 $120

with

Opti

onal

Bene

fitRi

der 0

MJ3W

$0 $0 w

ith O

ption

al Be

nefit

Ride

r 0MJ

3W

$120

$0 All C

osts

All C

osts

9

BC

15.D

-MN

EXTE

NDED

BAS

IC P

LAN

- NM2

7ME

DICA

RE (P

ART

A) -

HOSP

ITAL

SER

VICE

S - P

ER B

ENEF

IT P

ERIO

D*A

bene

fit pe

riod b

egins

on th

e firs

t day

you r

eceiv

e ser

vice a

s an i

npati

ent in

a ho

spita

l and

ends

after

you h

ave b

een o

ut of

the h

ospit

al an

d hav

e not

rece

ived

skille

d car

e in a

ny ot

her f

acilit

y for

60 da

ys in

a ro

w.Se

rvice

sMe

dicar

e Pay

sPl

an N

M27 P

ays

You P

ayHO

SPIT

ALIZ

ATIO

N*Se

mipr

ivate

room

and b

oard

, gen

eral

nursi

ng an

d misc

ellan

eous

servi

ces

and s

uppli

esFir

st 60

days

All b

ut $1

,316

$1,31

6 (Pa

rt A

Dedu

ctible

)$0

61st t

hrou

gh 90

th day

All b

ut $3

29 a

day

$329

a da

y$0

91st d

ay an

d afte

r:W

hile u

sing 6

0 life

time

rese

rve da

ysAl

l but

$658

a da

y$6

58 a

day

$0

Beyo

nd th

e add

itiona

l 150

days

$010

0% of

Med

icare

Eligi

ble E

xpen

ses

$0

SKILL

ED N

URSI

NG F

ACILI

TY C

ARE*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a hos

pital

for at

leas

t 3 da

ys an

den

tered

a Me

dicar

e app

rove

d fac

ility

withi

n 30 d

ays a

fter le

aving

the

hosp

ital. Fir

st 20

days

All a

ppro

ved a

moun

ts$0

$0

21st t

hrou

gh 10

0th day

All b

ut $1

64.50

a da

yUp

to $1

64.50

a da

y$0

101st d

ay an

d afte

r$0

80%

of co

vere

d exp

ense

s up t

o 120

days

per y

ear

Expe

nses

not p

aid by

polic

y

BLOO

DFir

st 3 p

ints

$03 p

ints

$0Ad

dition

al am

ounts

100%

$0$0

HOSP

ICE

CARE

You m

ust m

eet M

edica

re's

requ

ireme

nts, in

cludin

g a do

ctor's

certif

icatio

n of te

rmina

l illne

ss.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce f

or ou

tpatie

ntdr

ugs a

nd in

patie

nt re

spite

care

Medic

are c

opay

ment/

coins

uran

ce$0

10

BC

15.D

-MN

EXTE

NDED

BAS

IC P

LAN

- NM2

7ME

DICA

RE (P

ART

B) -

MEDI

CAL S

ERVI

CES

- PER

CAL

ENDA

R YE

AR

Servi

ces

Medic

are P

ays

Plan

NM2

7 Pay

sYo

u Pay

MEDI

CAL

EXPE

NSES

—IN

OR

OUT

OF T

HE H

OSPI

TAL A

NDOU

TPAT

IENT

HOS

PITA

L TRE

ATME

NT, s

uch a

s phy

sician

’s se

rvice

s,inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s,ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment Fir

st $1

83 of

Med

icare

App

rove

d Amo

unts*

*$0

$183

(Par

t B D

educ

tible)

$0

Rema

inder

of M

edica

re A

ppro

ved A

moun

ts80

%20

%***

$0Pa

rt B

Exce

ss C

harg

es (a

bove

Med

icare

App

rove

d Amo

unts)

$010

0%$0

BLOO

DFir

st 3 p

ints

$0Al

l cos

ts$0

Next

$183

of M

edica

re A

ppro

ved A

moun

ts*$0

$183

(Par

t B D

educ

tible)

$0

Rema

inder

of M

edica

re A

ppro

ved A

moun

ts80

%20

%$0

CLIN

ICAL

LAB

ORAT

ORY

SERV

ICES

—TE

STS

FOR

DIAG

NOST

ICSE

RVIC

ES10

0%$0

$0

**Onc

e you

have

been

bille

d $18

3 of M

edica

re A

ppro

ved A

moun

ts for

cove

red s

ervic

es, y

our P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

.***

Part

B co

insur

ance

(gen

erall

y 20%

of M

edica

re ap

prov

ed ex

pens

es),

or in

the c

ase o

f hos

pital

outpa

tient

depa

rtmen

t ser

vices

unde

r a pr

ospe

ctive

paym

ent

syste

m, ap

plica

ble co

paym

ents.

11

BC

15.D

-MN

EXTE

NDED

BAS

IC P

LAN

- NM2

7ME

DICA

RE (P

ART

B) -

MEDI

CAL S

ERVI

CES

- PER

CAL

ENDA

R YE

AR (c

ontin

ued)

PART

S A

AND

B**O

nce y

ou ha

ve be

en bi

lled $

183 o

f Med

icare

App

rove

d Amo

unts

for co

vere

d ser

vices

, you

r Par

t B D

educ

tible

will h

ave b

een m

et for

the c

alend

ar ye

ar.

Servi

ces

Medic

are P

ays

Plan

NM2

7 Pay

sYo

u Pay

HOME

HEA

LTH

CARE

—ME

DICA

RE A

PPRO

VED

SERV

ICES

Medic

ally n

eces

sary

skille

d car

e ser

vices

and m

edica

l sup

plies

100%

$0$0

Dura

ble m

edica

l equ

ipmen

tFir

st $1

83 of

Med

icare

App

rove

d Amo

unts*

$0$1

83 (P

art B

Ded

uctib

le)$0

Rema

inder

of M

edica

re A

ppro

ved A

moun

ts80

%20

%$0

OTHE

R BE

NEFI

TS –

NOT

COVE

RED

BY M

EDIC

ARE

FORE

IGN

TRAV

EL—

NOT

COVE

RED

BY M

EDIC

ARE

Medic

ally n

eces

sary

emer

genc

y car

e ser

vices

durin

g tra

vel o

utside

the

USA

$080

% of

cove

red e

xpen

ses

Expe

nses

not p

aid by

Medic

are o

r the

polic

yPR

EVEN

TIVE

MED

ICAL

CAR

E BE

NEFI

T--

NOT

COVE

RED

BY M

EDIC

ARE

Annu

al ph

ysica

l and

prev

entiv

e tes

ts an

d ser

vices

such

as: fe

cal o

ccult

blood

test,

digit

al re

ctal e

xam,

mam

mogr

am, h

earin

g scre

ening

dips

tick

urina

lysis,

diab

etes s

creen

ing, th

yroid

functi

on te

st, in

fluen

za sh

ot,tet

anus

and d

iphthe

ria bo

oster

and e

duca

tion,

admi

nister

ed or

orde

red

by yo

ur do

ctor w

hen n

ot co

vere

d by M

edica

re.

First

$120

each

calen

dar y

ear

Addit

ional

Char

ges

$0 $0

$120

$0

$0 All C

osts

12

BC

A15

.D-M

N

The c

harts

sum

mar

izing

Med

icare

ben

efits

onl

y brie

fly d

escr

ibe t

he b

enef

its.

The H

ealth

Car

e Fin

ancin

g Ad

min

istra

tion

or it

s Med

icare

pub

licat

ion

shou

ld b

e con

sulte

d fo

r fur

ther

det

ails a

nd lim

itatio

ns.

Your

Poli

cy al

so pr

ovide

s the

follo

wing

bene

fits:

1.Al

coho

lism,

Che

mica

l Dep

ende

ncy,

Drug

Add

iction

.Whe

n you

rece

ive tr

eatm

ent in

a lic

ense

d hos

pital,

resid

entia

l trea

tmen

t pro

gram

or no

nres

identi

altre

atmen

t pro

gram

for a

lcoho

lism,

chem

ical d

epen

denc

y or d

rug a

ddict

ion, w

e will

pay b

enefi

ts on

the s

ame b

asis

as co

vera

ge fo

r any

othe

r con

dition

.Co

vera

ge fo

r con

finem

ent in

a ho

spita

l and

a re

siden

tial tr

eatm

ent p

rogr

am is

limite

d to 2

8 day

s of c

onfin

emen

t eac

h cale

ndar

year

.Co

vera

ge fo

r tre

atmen

t in a

nonr

eside

ntial

treatm

ent p

rogr

am is

limite

d to 1

30 ho

urs i

n a ca

lenda

r yea

r.Be

nefits

are n

ot pa

yable

for t

hat p

ortio

n of e

xpen

se th

at is

paid

by M

edica

re or

paid

unde

r any

othe

r par

t of y

our p

olicy

.2.

Scalp

Hair

Pro

sthes

is.W

e will

pay t

he ex

pens

e inc

urre

d on t

he sa

me ba

sis as

any o

ther S

ickne

ss or

Injur

y and

as if

Medic

are p

aid be

nefits

for a

scalp

hair

pros

thesis

need

ed be

caus

e of h

air lo

ss su

ffere

d as a

resu

lt of a

lopec

ia ar

eata.

Only

the fir

st $3

50.00

of ex

pens

e inc

urre

d in a

calen

dar y

ear w

ill be

cons

idere

das

expe

nse u

nder

this

part

of yo

ur po

licy.

Amou

nts in

exce

ss of

the U

sual

and C

ustom

ary C

harg

e are

not c

onsid

ered

expe

nse.

Bene

fits ar

e not

paya

ble fo

r tha

tpo

rtion o

f exp

ense

that

is pa

id by

Med

icare

or pa

id un

der a

ny ot

her p

art o

f this

polic

y.3.

Routi

ne S

creen

ing P

roce

dure

s for

Can

cer.

We w

ill pa

y the

expe

nse i

ncur

red t

hat is

not p

aid by

Med

icare

or pa

id un

der a

ny ot

her p

art o

f you

r poli

cy fo

r rou

tine

scre

ening

proc

edur

es fo

r can

cer,

includ

ing m

ammo

gram

s and

Pap

smea

r.4.

Temp

orom

andib

ular J

oint D

isord

er an

d Cra

nioma

ndibu

lar D

isord

er.

Bene

fits ar

e pay

able

for th

e sur

gical

and n

onsu

rgica

l trea

tmen

t of te

mpor

oman

dibula

r joint

disor

der a

nd cr

aniom

andib

ular d

isord

er on

the s

ame b

asis

as th

at for

trea

tmen

t to an

y othe

r joint

in th

e bod

y.Su

ch tr

eatm

ent m

ust b

e adm

iniste

red o

rpr

escri

bed b

y a ph

ysici

an or

denti

st.Be

nefits

are n

ot pa

yable

unde

r this

part

of yo

ur po

licy f

or an

y exp

ense

paya

ble un

der a

nothe

r par

t of th

e poli

cy.

5.Re

cons

tructi

ve S

urge

ry.Be

nefits

are p

ayab

le for

reco

nstru

ctive

surg

ery o

n the

same

basis

as th

at for

any o

ther s

urge

ry if t

he re

cons

tructi

ve su

rger

y is i

ncide

ntal

to or

follo

ws su

rger

y res

ulting

from

injur

y, sic

knes

s or o

ther d

iseas

e of th

e inv

olved

part.

Bene

fits ar

e not

paya

ble un

der t

his po

licy f

or an

expe

nse p

ayab

leun

der a

nothe

r par

t of th

e poli

cy.

6.Su

rgica

l Cen

ter S

ervic

es.B

enefi

ts ar

e pay

able

for su

rgica

l cen

ter se

rvice

s for

healt

h car

e tre

atmen

t or s

ervic

e ren

dere

d by a

free

stand

ing am

bulat

ory s

urgic

alce

nter o

r fac

ilities

offer

ing am

bulat

ory m

edica

l ser

vice 2

4 hou

rs a d

ay, 7

days

a we

ek, w

hich a

re no

t par

t of a

hosp

ital, b

ut ha

ve be

en re

viewe

r and

appr

oved

bythe

state

comm

ission

er of

comm

erce

to pr

ovide

the t

reatm

ent o

r ser

vice o

n the

same

basis

as co

vera

ge pr

ovide

d for

the s

ame h

ealth

care

trea

tmen

t or s

ervic

ere

nder

ed by

a ho

spita

l.Be

nefits

are n

ot pa

yable

unde

r this

part

of yo

ur po

licy f

or an

expe

nse p

ayab

le un

der a

nothe

r par

t of th

e poli

cy.

7.Im

muniz

ation

Ben

efits.

We w

ill pa

y the

expe

nse i

ncur

red f

or an

immu

nizati

on re

ceive

d by y

ou.B

enefi

ts ar

e not

paya

ble fo

r tha

t por

tion o

f exp

ense

for w

hich

bene

fits w

ere p

aid by

Med

icare

or un

der a

ny ot

her p

ortio

n of th

e poli

cy.

8.Ph

enylk

etonu

ria T

reatm

ent.

Bene

fits ar

e pay

able

for sp

ecial

dieta

ry tre

atmen

t for p

heny

lketon

uria

when

reco

mmen

ded b

y a ph

ysici

an.

9.Di

abete

s Equ

ipmen

t and

Sup

plies

.We w

ill pa

y the

Usu

al an

d Cus

tomar

y cha

rge f

or ex

pens

e inc

urre

d for

all P

hysic

ian pr

escri

bed m

edica

lly ap

prop

riate

and

nece

ssar

y equ

ipmen

t and

supp

lies u

sed i

n the

man

agem

ent a

nd tr

eatm

ent o

f diab

etes,

not o

therw

ise co

vere

d und

er M

edica

re or

Par

t D of

the M

edica

rePr

ogra

m.Co

vera

ge m

ust in

clude

perso

ns w

ith ge

statio

nal, t

ype I

, or t

ype I

I diab

etes.

Bene

fits w

ill be

limite

d to 8

0% of

the U

sual

and C

ustom

ary C

harg

e not

cove

red b

y Med

icare

or P

art D

of th

e Med

icare

Pro

gram

.10

.Rou

tine P

rosta

te Ca

ncer

Scre

ening

.We w

ill pa

y the

expe

nse i

ncur

red f

or pr

ostat

e can

cer s

creen

ing.B

enefi

ts ar

e lim

ited t

o at le

ast o

ne sc

reen

ing pe

r yea

r for

any i

nsur

ed m

ale 50

year

s of a

ge or

olde

r, an

d at le

ast o

ne sc

reen

ing pe

r yea

r for

any i

nsur

ed m

ale 40

year

s of a

ge or

olde

r who

is sy

mptom

atic.

11.O

utpati

ent M

ental

Hea

lth C

over

age.

We w

ill pa

y the

allow

able

amou

nt no

t paid

by M

edica

re, le

ss th

e Par

t B D

educ

tible

if app

licab

le.12

.Phy

sical

and O

ccup

ation

al Th

erap

y Ser

vices

.We w

ill pa

y the

allow

able

amou

nt no

t paid

by M

edica

re, le

ss th

e Par

t Be D

educ

tible

if app

llicab

le.13

.Tre

atmen

t of L

yme D

iseas

e.W

e will

pay b

enefi

ts for

diag

nose

d Lym

e dise

ase a

s any

othe

r med

ical s

ervic

e.Be

nefits

will

not b

e pay

able

for th

at po

rtion o

fex

pens

e tha

t is pa

id by

Med

icare

or un

der a

ny ot

her p

art o

f you

r poli

cy. 13

BC

A15

.D-M

N

ADDI

TION

AL B

ENEF

ITS

UNDE

R EX

TEND

ED B

ASIC

PLA

N -N

M27

We w

ill pa

y 80%

of th

e usu

al an

d cus

tomar

y cha

rges

for t

he fo

llowi

ng ar

ticles

and s

ervic

espr

escri

bed b

y a ph

ysici

an w

hich a

re no

t paid

by M

edica

re or

paya

ble un

der a

ny ot

her p

rovis

ion of

your

polic

y.

1.Ho

spita

l ser

vices

.2.

Profe

ssion

al se

rvice

s for

the d

iagno

sis or

trea

tmen

t of in

juries

, sick

ness

or co

nditio

ns w

hen s

uch s

ervic

es ar

e give

n by a

phys

ician

or ar

e und

er a

phys

ician

'sdir

ectio

n.Ou

tpatie

nt me

ntal o

r den

tal se

rvice

s are

not c

over

ed.

3.Se

rvice

s of a

nursi

ng ho

me fo

r not

more

than

120 d

ays e

ach y

ear.

Such

servi

ces m

ust q

ualify

as re

imbu

rsable

unde

r Med

icare

.4.

Servi

ces o

f a ho

me he

alth a

genc

y.Su

ch se

rvice

s mus

t qua

lify as

reim

bursa

ble un

der M

edica

re.

5.Us

e of r

adium

or ot

her r

adioa

ctive

mate

rials.

6.Ox

ygen

.7.

Anes

thetic

s.8.

Pros

thetic

devic

es ot

her t

han d

ental

.9.

Renta

l or p

urch

ase,

as ap

prop

riate,

of du

rable

med

ical e

quipm

ent o

ther t

han e

yegla

sses

and h

earin

g aids

.10

.Diag

nosti

c X-ra

ys an

d lab

tests

.11

.Ora

l sur

gery

for: (

a) pa

rtially

or co

mplet

ely un

erup

ted im

pacte

d tee

th, (b

) a to

oth ro

ot wi

thout

the ex

tracti

on of

the e

ntire

root

or (c

) the

gums

or tis

sues

of th

emo

uth w

hen n

ot pe

rform

ed in

conn

ectio

n with

the e

xtrac

tion o

r rep

air of

teeth

.12

.Ser

vices

of a

phys

ical th

erap

ist.

13.P

rofes

siona

l amb

ulanc

e for

servi

ce to

the n

eare

st fac

ility q

ualifi

ed to

trea

t the c

ondit

ion, o

r a re

ason

able

milea

ge ra

te for

tran

spor

tation

to a

kidne

y dial

ysis

cente

r for

trea

tmen

t.14

.Well

-bab

y car

e.15

.Up t

o $50

0.00 f

or a

seco

nd su

rgica

l opin

ion.N

ot inc

luded

is th

e rep

etitio

n of d

iagno

stic t

ests.

16.S

ervic

es of

an oc

cupa

tiona

l ther

apist

.

The a

bove

Add

itiona

l Ben

efits

are n

ot pa

yable

for:

(a) in

juries

or si

ckne

ss fo

r whic

h any

bene

fits ar

e pro

vided

for b

y wor

kers'

comp

ensa

tion o

r emp

loyer

's lia

bility

laws,

(b) c

osme

tic su

rger

y, ex

cept

for re

pair o

f an i

njury

or a

birth

defec

t, (c)

care

whic

h is p

rimar

ily fo

r cus

todial

or fo

r dom

icilia

ry pu

rpos

es w

hich w

ould

not q

ualify

as el

igible

servi

ces u

nder

Med

icare

, (d)

any c

harg

e for

confi

neme

nt in

a priv

ate ro

om to

the e

xtent

it is i

n exc

ess o

f the i

nstitu

tions

' cha

rge f

or its

mos

t com

mon

semi

priva

te ro

om un

less t

he pr

ivate

room

is pr

escri

bed a

s med

ically

nece

ssar

y by a

phys

ician

or (e

) any

char

ges f

or se

rvice

s or a

rticles

the p

rovis

ion of

whic

h is

not w

ithin

the sc

ope o

f auth

orize

d pra

ctice

of th

e ins

titutio

n or in

dividu

al re

nder

ing th

e ser

vices

or ar

ticles

.

LIMI

TATI

ONS

The p

olicy

DOE

S NO

T co

ver t

he fo

llowi

ng:

a)Pr

ivate

Duty

Nursi

ng.

b)Cu

stodia

l nur

sing h

ome c

are c

osts.

c)Int

erme

diate

nursi

ng ho

me ca

re co

sts.

d)Ph

ysici

ans c

harg

es ab

ove M

edica

re's

appr

oved

char

ges,

exce

pt as

expla

ined i

n the

Add

itiona

l Ben

efits

secti

on of

this

outlin

e.

14

BC

A15

.D-M

N

OPTI

ONAL

COV

ERAG

E AV

AILA

BLE

FOR

BASI

C PL

AN -

NM26

(chec

k if a

pplie

d for

)0N

R6F

- Par

t B E

xces

s Rid

erIf y

ou in

cur s

ervic

es or

supp

lies,

outsi

de of

Minn

esota

, that

are e

ligibl

e und

er th

e Med

icare

Par

t B, w

e will

pay t

hat p

ortio

n of th

e usu

al an

d cus

tomar

ych

arge

whic

h:a)

is in

exce

ss of

the M

edica

re P

art B

appr

oved

char

ge an

db)

you a

re re

quire

d to p

ay.

0NR3

F - M

edica

re P

art A

Hos

pita

l Ded

uctib

le Be

nefit

s Rid

erW

hen y

ou ar

e hos

pital

confi

ned f

or a

cove

red c

ondit

ion, w

e will

pay t

he M

edica

re P

art A

Hos

pital

Dedu

ctible

of $1

,316 t

hat y

ou in

cur.

0NR5

F - P

reve

ntive

Med

ical C

are R

ider

We w

ill pa

y the

Med

icare

-app

rove

d amo

unt fo

r eac

h of th

e foll

owing

prev

entiv

e hea

lth se

rvice

s, as

if Me

dicar

e wer

e to c

over

the s

ervic

e, as

iden

tified

in th

eAm

erica

n Med

ical A

ssoc

iation

's cu

rrent

proc

edur

al ter

mino

logy (

AMA

CPT)

code

s, to

a max

imum

of $1

20.00

annu

ally u

nder

this

bene

fit:a)

an an

nual

clinic

al pr

even

tive m

edica

l hist

ory a

nd ph

ysica

l exa

m tha

t may

inclu

de te

sts an

d ser

vices

from

item

(b) b

elow

and p

atien

t edu

catio

n to

addr

ess p

reve

ntive

healt

h car

e mea

sure

s;b)

any o

ne or

comb

inatio

n of th

e foll

owing

prev

entiv

e scre

ening

tests

or pr

even

tive s

ervic

es, a

s ofte

n as m

edica

lly ne

cess

ary;

feca

l occ

ult bl

ood t

est a

nd/or

digita

l recta

l exa

m; di

pstic

k urin

alysis

for h

ematu

ria, b

acter

iuria,

and p

rotei

nuria

; pur

e ton

e (air

only)

hear

ing sc

reen

ing te

st, or

dere

d or a

dmini

stere

d by a

phys

ician

; ser

um ch

oleste

rol s

creen

ing ev

ery f

ive ye

ars;

thyro

id fun

ction

test;

diab

etes s

creen

ing; a

nd/or

any o

ther t

ests

or pr

even

tive m

easu

res

deter

mine

d app

ropr

iate b

y the

atten

ding p

hysic

ian.

Bene

fits fo

r Pre

venti

ve H

ealth

Ser

vices

will

not d

uplic

ate an

y pay

ment

for a

proc

edur

e tha

t is al

read

y cov

ered

by M

edica

re.

0NR4

F - M

edica

re P

art B

Ded

uctib

le Ri

der

Whe

n you

incu

r exp

ense

that

is ap

plied

to th

e Med

icare

Par

t B de

ducti

ble an

d Med

icare

does

not p

ay th

e ded

uctib

le, w

e will

pay t

he en

tire M

edica

re P

art B

annu

al de

ducti

ble.

15

Preferred Method of Communication (Select one) Phone Fax Email Contact info: ______________________________________________________________

Note: Producers must be under the same commission code to share or split commissions. Please update your contact information at http://www.mutualofomaha.com/.

Provide Applicant with the Guide to Health Insurance for People with Medicare Provide Applicant with the Outline of Coverage

• Calculate the premium based on age at application date Application (complete in full)

Sections A & B: Plan and Applicant Information• Select plan• Enter Requested Effective Date• Indicate where the policy is to be mailedSection C: Medicare Information• Include applicant’s Medicare claim number on the application. This number is required for

electronic claim processing. If this number is not available at time of application, the applicant/agent must provide this number by calling 1-877-617-5587 once it is received. If not already covered by Medicare, indicate “eligibility” and “enrollment” dates.

Section D: Previous or Existing Coverage Information• Please complete ALL questions in full

For Sections E and F – Refer to the Open Enrollment/Guaranteed Issue worksheet to help identify eligibility.

Section E: Please answer all of the following questions• If either Applicant A or B answered “YES” to question 7 OR BOTH questions 8 and 9 in Section E,

they can skip to Section H Sections F & G: Health/Medication Information

• Do NOT answer if applicant is in an open enrollment or guaranteed issue periodSection H: Agreement and Authorization• Make sure applicant(s) sign and date the applicationSection J: To be Completed by Producer• Make sure producer(s) sign and date the application

Complete the Method of Payment form and return with the completed application• Use premium determined by the Outline of Coverage• The full modal premium is collected at the time of application

Complete Replacement Notice and leave a copy with the applicant (if applicable) Provide Applicant with Premium Receipt signed by agent (if applicable), and provide Applicant

with Notice of Information Practices Complete the Agent Information Form and leave with the applicant Provide applicant with completed and signed copy of application before submitting original

application for processing.

Note: An interviewer may call to verify/confirm the information provided on the application.

Minnesota Producer Information – Please Complete

Application Submission Checklist – Omaha Ins. Co. Medicare Supplement Coverage

NAP175_MN_0815

NA

P175

_MN

_081

5

✍

Producer Name Agent Writing Number Commission Share Commission Code or Social Security Number Required only if you are not appointed or licensed or are changing brokerage firms

___________________________ %

___________________________ %

Open Enrollment and Guaranteed Issue Worksheet

M27788_0815

M27

788_

0815

If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period: (Situations may vary by state and coverage may be limited. Please refer to the Underwriting Guide for more information.)

ELIGIBILITY FOR OPEN ENROLLMENT

Applicant is:• at least 64 ½ years of age (in most states) and within six months before or after his/her effective

date for Medicare Part B, or• covered under Medicare Part B prior to age 65 (eligible for a six-month open enrollment period

upon reaching age 65)Note: Coverage cannot be effective until your Medicare coverage is effective.

ELIGIBILITY FOR GUARANTEED ISSUE

Evidence of eligibility is required for the following situations.Applicant:

• is in the original Medicare plan, has an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays, and that coverage is ending

• is in the original Medicare plan, has a Medicare Select policy, and moves out of the Select plan’s service area

• loses coverage due to their Medicare supplement insurance company’s insolvency or at no fault of the applicant

• the applicant leaves their Medicare supplement plan because the company has not followed rules, or has misled the applicant

Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant’s state by any insurance company.

Applicant was enrolled in a Medicare Advantage (MA) plan, and:

• the plan is leaving the Medicare program or stops service in the applicant’s area, or the applicant moves out of the plan’s service area (applicant must switch back to original Medicare)

• the applicant leaves the plan because the company has not followed rules, or has misled the applicant

Applicant has the right to buy Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant’s state by any insurance company.

• the applicant decided to switch to original Medicare within the first year of joining a MA plan when first eligible for Medicare Part A at age 65

Applicant has the right to buy any Medicare supplement plan that is sold in the applicant’s state by any insurance company.

• after dropping their Medicare supplement policy to join a MA plan for the first time, has been on the MA plan less than one year and wants to switch back

Applicant has the right to obtain their Medicare supplement policy back if that carrier still sells it or, if not available, buy any Medicare supplement Plan A, B, C, F, K or L that is sold in the applicant’s state by any insurance company.

Applicant was enrolled in a Medicaid plan or state-specific variation of a Medicaid plan, and:

• the applicant's state has Guaranteed Issue or Open Enrollment Rights for the loss of Medicaid or state-specific variation of a Medicaid plan

Reference the Underwriting Guidelines for states that have Guarantee Issue or Open Enrollment Rights for loss of Medicaid or state-specific variation of a Medicaid plan.

Acceptable Evidence of Eligibility:a. Copy of the applicant’s MA plan’s termination noticeb. Copy of the letter the applicant sent to his/her MA plan requesting disenrollmentc. Signed statement that the applicant has requested to be disenrolled from his/her MA pland. Certification of group coveragee. Copy of the termination letter from employer or group carrierf. Image of insurance ID card (ONLY allowed if your MA plan is being terminated)g. Copy of the termination letter that the applicant received regarding their state Medicaid plan or state-specific variation of a Medicaid plan

NA6008-21 Omaha Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608 1

NA

6008

-21

Applicant acknowledges and agrees that if there is more than one applicant on this application, all information provided may be viewed or shared with the other applicant.

A. Plan Information (to be completed by Producer)

Omaha Insurance CompanyA Mutual of Omaha Company

Application for Medicare Supplement Coverage

Applicant A Applicant B

DNIS ________________ Auth # _________________

Agent Writing # Group # (if applicable) ______________ Keyline _________________

Plan

Basic Policy - NM26Optional Riders (only available for Basic Policy)

Part A Deductible - 0NR3F

Part B Deductible - 0NR4F

Preventative Care - 0NR5F

Part B Excess - 0NR6FExtended Basic Policy - NM27

Requested Effective Date

Deliver Policy to

Applicant A Producer

/ / / /

Plan

Basic Policy - NM26Optional Riders (only available for Basic Policy)

Part A Deductible - 0NR3F

Part B Deductible - 0NR4F

Preventative Care - 0NR5F

Part B Excess - 0NR6FExtended Basic Policy - NM27

Requested Effective Date

Deliver Policy to

Applicant B Producer

Applicant A Applicant B

B. Applicant Information

Name (First/Middle Initial/Last)

Residence Address

City

State ZIP

Mailing Address (if different from residence address)

City

State ZIP

Home Phone

(area code)E-mail Address

Current Age ________

Date of Birth mo day yr

Male Female

Social Security #

Height Weight Ft In Lbs

Name (First/Middle Initial/Last)

Residence Address (if different from Applicant A’s)

City

State ZIP

Mailing Address (if different from residence address)

City

State ZIP

Home Phone

(area code)E-mail Address

Current Age ________

Date of Birth mo day yr

Male Female

Social Security #

Height Weight Ft In Lbs

/ / / /

– – – –

– – – –

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Applicant A Applicant B

B. Applicant Information (continued)

Have you used tobacco in any form in the past 12 months? ........................................................ Y N

Have you used tobacco in any form in the past 12 months?......................................................... Y N

Go paperless! To receive your Explanation of Benefits (EOBs) online, select “YES” below and provide your current e-mail address in Section B. If you subscribe, you will not receive paper EOBs, but instead, will receive an e-mail notification when new EOBs become available with a link to access each specific EOB. We will continue to mail EOBs if you are entitled to receive any monetary reimbursement from Omaha Insurance Company.

Receive statement online? ................................... Y N Receive statement online? ................................... Y N

Medicare Claim Number

Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date

/ /

Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll

/ /

Medicare Claim Number

Medicare Part A Effective Date / / If you are not covered under Medicare Part A, what is your eligibility date

/ /

Medicare Part B Effective Date / / If you are not covered under Medicare Part B, indicate the date you plan to enroll

/ /

Applicant A Applicant B

C. Medicare Information

Please reference your Medicare card to complete this section.

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If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Please mark “YES” or “NO” with an “X” to the questions below.

Applicant B

Name of Company

Plan

Applicant A

Y N

Y N

Y N

Y N

Y N

Applicant B Y N

Y N

Y N

Y N

Y N

Applicant A

Y N

Applicant B

Y N

D. Previous or Existing Coverage Information

(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy?................................................

(c) Planned date of termination/disenrollment?........................................... Applicant A / /

Applicant B / /

(d) Was this your first time in this type of Medicare plan?............................................... (e) Did you drop a Medicare supplement or Medicare Select policy/certificate to enroll in this Medicare plan?..................................................................................................

(f) Is your former Medicare supplement or Medicare Select policy certificate still available?

To the Best of Your Knowledge and Belief:3. Are you covered for medical assistance through the state Medicaid program?.................

(NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer “NO” to this question.) If “YES,” answer the following about this existing coverage:

(a) Will Medicaid pay your premiums for this Medicare supplement policy?................... (b) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?........................................................................................

4. Do you have another Medicare supplement or Medicare Select insurance policy or certificate in force?.......................................................................................................... If “YES,” answer the following about this existing coverage: (a) Do you intend to replace your current Medicare supplement policy/certificate with this policy?....................................................................................................................

(b) Indicate planned termination or disenrollment date............................... Applicant A / /

Applicant B / / (c) With what company, and what plan do you have?

5. Have you had coverage from any Medicare plan other than Medicare Part A or B within the past 63 days? (for example, a Medicare Advantage plan, or a Medicare HMO or PPO)...... If “YES,” answer the following about this previous or existing coverage:

(a) Fill in your start and end dates below. If you are still covered under this plan, leave “END” blank......................................................................... Applicant A START / /

END / /

Applicant B START / /

END / /

Please answer questions regarding another Medicare supplement or Select plan:

Y N Y N

Y N

Y N

Y N

Y N

Y N

Y N

Applicant A

Name of Company

Plan

Please answer questions regarding Medicare plan coverage (other than Medicare supplement):

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Please answer questions regarding other health insurance:Applicant A

Y N

Applicant B

Y N 6. Have you had coverage under any other health insurance within the past 63 days?.......... (For example, an employer group health plan, union plan, or individual non-Medicare supplement plan.) If “YES,” answer the following about this previous or existing coverage: (a) What are your dates of coverage under the other policy/certificate? If you are still covered under this plan, leave “END” blank................ Applicant A START / /

END / /

Applicant B START / /

END / /

(b) Planned date of termination/disenrollment?............................................ Applicant A / /

Applicant B / /

(c) Have you disenrolled from your current coverage voluntarily?................................... (d) Please state the reason for your disenrollment:

________________________________________________________ Applicant A________________________________________________________

Applicant B (e) With what company and what kind of policy/certificate? (List below.)

Applicant B

Name of Company

Policy/Certificate type

Applicant A

Applicant B

(g) Please indicate reason for termination/disenrollment: ■ Your Medicare Advantage plan is leaving the Medicare program.................................■ Your Medicare Advantage organization stopped offering Medicare Advantage plans.......■ Your Medicare Advantage organization stopped offering coverage in the area in which you live............................................................................................................■ You moved out of the geographic service area of your Medicare Advantage plan..........■ You had a Medicare Advantage plan with Medicare Part D benefits and are enrolling in a stand-alone Medicare Part D plan...........................................................................

■ Other: ________________________________________________________ Applicant A

_________________________________________________________ Applicant B

To the Best of Your Knowledge and Belief:

7. Are you applying during a guaranteed issue period?........................................................ (NOTE: Refer to the guaranteed issue worksheet to help identify if you are eligible. If the answer above is “YES,” attach proof of eligibility, such as your coverage termination letter.)8. Did you turn age 65 in the last six months?..................................................................... 9. Did you enroll in Medicare Part B in the last six months?.................................................

If “YES,” indicate your Part B effective date............................................... Applicant A / /

Applicant B / /

IF YOU ANSWER “YES” TO QUESTION 7 OR BOTH QUESTIONS 8 AND 9 IN SECTION E, OR ARE OTHERWISE IN AN OPEN ENROLLMENT PERIOD, SKIP SECTIONS F & G AND GO TO SECTION H.

E. Please answer all of the following questions:Applicant A

Y N

Y N

Y N

Applicant B

Y N

Y N

Y N

Applicant A

Name of Company

Policy/Certificate type

Check box(s) below if applicable

Y N Y N

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F. Health Information For all plans, answer questions 10-20. (If “YES” is answered to any of the following questions 10-19, that person is not eligible for coverage.)

Applicant A Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Applicant B Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

To the Best of Your Knowledge and Belief:10. Are you currently confined to a wheelchair or any motorized mobility device?..........................11. Are you currently hospitalized, confined to a bed, in a nursing home or assisted living

facility?....................................................................................................................................12. Are you currently receiving any occupational, speech or physical therapy?..............................13. Have you been advised by a medical professional to have treatment, further diagnostic

evaluation, diagnostic testing, follow up visits or any surgery that has not been performed?...14. At any time have you been medically diagnosed with, treated for, or had surgery for any of

the following:A. Chronic kidney disease, kidney failure, or kidney disease requiring dialysis? ....................B. Emphysema, Chronic Obstructive Pulmonary Disease (COPD), any other chronic

pulmonary disorder or any cardio-pulmonary disorder requiring oxygen?..........................

C. Alzheimer’s Disease, dementia or any other cognitive disorder? .......................................

D. Parkinson’s Disease, multiple sclerosis or amyotrophic lateral sclerosis (Lou Gehrig’s Disease)?...........................................................................................................................

E. Systemic Lupus, scleroderma or myasthenia gravis? .........................................................

F. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? ................

G. An organ transplant or been advised to have an organ transplant (excluding cornea transplants)? .....................................................................................................................

H. Chronic hepatitis or cirrhosis? ...........................................................................................

I. Osteoporosis with fractures? .............................................................................................15. Do you have diabetes? ............................................................................................................ 16. Do you have an implanted cardiac defibrillator? ...................................................................... 17. Within the past two years, have you been treated for, or been advised by a physician to

have treatment for: A. Coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery or

stent placement? ...............................................................................................................

B. Cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, peripheral artery disease, peripheral venous thrombotic disease, vascular angioplasty, endarterectomy, carotid artery disease, any heart or heart valve disorder, atrial fibrillation, other heart

rhythm disorder, or implantation of a pacemaker?.............................................................

C. Alcoholism or drug abuse? ................................................................................................

D. Any mental or nervous disorder requiring treatment (including hospital confinement) by a psychiatrist, psychologist, counselor or therapist? .....................................................

E. Internal cancer, lymphoma or melanoma? ........................................................................

F. A stroke or transient ischemic attack (TIA)? .......................................................................G. Degenerative bone disease, spinal stenosis, rheumatoid arthritis, psoriatic arthritis,

arthritis that restricts mobility or have you been advised to have a joint replacement?........18. Have you been advised by a medical professional that surgery may be required within the

next 12 months for cataracts? .................................................................................................19. Have you been hospital confined three or more times in the past two years for a same or

similar condition? ...................................................................................................................

20. Have you taken any over-the-counter or prescription drugs in the past 24 months?................ (If YES, please complete the Medication Information sheet on the next page)

If you are applying during an open enrollment or guaranteed issue period: SKIP SECTIONS F & G and GO TO SECTION H. (Please see the enclosed material for explanation of the open enrollment and guaranteed issue periods.)

Note: The applicant does not have to disclose an HIV (AIDS virus) test which was administered: (1) to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who received the services of emergency medical service personnel at a hospital or medical care facility, corrections employee, or employee of a secure treatment facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services; or (4) to a person who has been the victim of an assault or any other crime which involves bodily contact with the offender.

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Applicant A

Applicant B

G. Medication Information If you are applying for ANY plan OUTSIDE of an open enrollment or guaranteed issue period, please list all over-the-counter or prescription medications you have taken in the past 24 months in the table below.

Medication Name (copy off pharmacy label) Dosage Frequency

Have you taken this medication for more than 2 years?

Prescribed by Primary Physician?

Diagnosis/Condition

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Medication Name (copy off pharmacy label) Dosage Frequency

Have you taken this medication for more than 2 years?

Prescribed by Primary Physician?

Diagnosis/Condition

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

Y N Y N

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IMPORTANT STATEMENTS■ You do not need more than one Medicare supplement policy.■ If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverage.■ You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.■ If, after purchasing the policy, you become eligible for Medicaid, the benefits and premiums under your Medicare

supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

■ If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension.

■ Counseling services may be available in Minnesota to provide advice concerning medical assistance through the state Medicaid program, Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

H. Agreement and Authorization

AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO OMAHA INSURANCE COMPANY■ I authorize any physician, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers,

other medical care facilities, health maintenance organizations and all other providers of medical or dental services, the group of companies which presently includes Omaha Insurance Company, Mutual of Omaha Insurance Company, United of Omaha Life Insurance Company, United World Life Insurance Company, Companion Life Insurance Company, and any additional companies which may become part of this group of companies and their successors, along with other persons and entities which act on behalf of those companies to provide services to them, employers, consumer reporting agencies, and other insurance companies to disclose Personal Information about me to Omaha Insurance Company. This authorization excludes the release of information about an HIV (AIDS Virus) test or a test to determine a bloodborne pathogen which was administered to: a criminal offender or crime victim as a result of a crime that was reported to the police; a patient who received the services of emergency medical service personnel at a hospital or medical care facility, corrections employee, or employee of a secure treatment facility; emergency medical personnel who were tested as a result of performing emergency medical services; or a person who has been the victim of an assault or any other crime which involves bodily contact with the offender. This Authorization shall be valid for 24 months after it is signed, or until any contract of insurance issued as a result of this application ends, whichever comes first. I understand that I may revoke this authorization at any time, by written notice to: ATTN: Individual Underwriting, Omaha Insurance Company, [P.O. Box 3608, Omaha, NE 68103-3608]. I realize that my right to revoke this authorization is limited to the extent that Omaha Insurance Company has taken action in reliance on the authorization or the law allows Omaha Insurance Company to contest the issuance of the policy or a claim under the policy.

■ “Personal Information” means all health information, such as medical history, mental and physical condition, prescription drug records, drug and alcohol use and other information such as finances, occupation, general reputation and insurance claims information about me. Personal Information does not include Psychotherapy Notes, which are notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a counseling session, which notes are separated from the rest of the person’s medical record. Certain information, such as that relating to prescriptions, diagnosis and functional status, is not included in the term Psychotherapy Notes.

■ The Personal Information will be used to determine my eligibility for insurance and to resolve or contest any issues of incomplete, incorrect or misrepresented information on my application which may arise during the processing of my application or in connection with claims for insurance benefits. This authorization will not be used if the applicant is in an open enrollment or guaranteed issue period.

■ If the person or entity to whom Personal Information is disclosed is not a health care provider or health plan subject to federal privacy regulations, the Personal Information may then be subject to further disclosure by that person or entity without the protections of the federal privacy regulations.

■ I understand that I may refuse to sign this application. I realize that if I refuse to sign, the insurance for which I am applying will not be issued.

■ I understand that I will receive a copy of the signed application. A copy of this application is as effective as the original. I acknowledge and agree that if there is more than one applicant on this application, all information provided may be reviewed or shared with the other applicant. I understand that, upon acceptance of the completed application, each applicant will receive a separate policy and a completed and signed application will become part of each applicant’s policy.

I represent that my answers and statements on this application are true and complete to the best of my knowledge and belief. I understand that my policy benefits can start no earlier than my Medicare effective date, my first month’s premium has been received and/or processed and my application has been approved by Omaha Insurance Company.I acknowledge receipt of A Guide to Health Insurance for People with Medicare (not applicable for Direct-to-Consumer business) and an Outline of Coverage.

✍ Dated at _______________________, on / / __________________________________ City State Month Day Year Applicant A’s Signature

✍ Dated at _______________________, on / / __________________________________ City State Month Day Year Applicant B’s Signature (if applying)

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21. Producers shall list any other health insurance policies/certificates they have sold to the applicant(s).(a) List policies/certificates sold to the applicant(s) which are still in force.

(b) List policies/certificates sold to the applicant(s) in the past five (5) years which are no longer in force.

I/We certify as follows:I/We have accurately recorded in the application the information supplied by the applicant(s)........................... Y N

I/We certify that we have interviewed the proposed applicant(s)........................................................................ Y N

If you answered “NO” to any of the above statements, please explain why. __________________________________________

_________________________________________________________________________________________________________

I acknowledge that if the applicant(s) is replacing coverage, I/We have provided a copy of the replacement notice.

✍ ________________________________________________ ✍ _____________________________________________ Signature of Licensed Producer Date Signature of Licensed Producer Date

________________________________________________________ ____________________________________________________ Printed Name Printed Name

Agent Writing Number Agent Writing Number

Applicant A

Applicant B

Applicant A

Applicant B

J. To be Completed by Producer

I. Producer Comments (please attach a separate sheet if needed)

Applicant A Account Type (check one): Checking Savings

__________________________________________________ Name of Financial Institution

Routing Number (9 digits on lower left side of check)

Account Number (Do NOT use Debit/Credit Card numbers)

__________________________________________________ Name as Shown on Account

Applicant B Same account as Applicant A Account Type (check one): Checking Savings

_________________________________________________ Name of Financial Institution

Routing Number (9 digits on lower left side of check)

Account Number (Do NOT use Debit/Credit Card numbers)

_________________________________________________ Name as Shown on Account

1. Account Owner Name, if different than applicant's...................... 2. If premium is NOT paid by Proposed Insured/Insured (includesspouse or joint-married account), indicate the bank account owner'srelationship to Proposed Insured/Insured by selecting one of the following. Employer (3 app minimum/applicant must be retired. Refer to List-Bill guidelines. N/A for Direct-to-Consumer business) Living Trust Power of Attorney or legal guardian (documentation required)

Business owned by applicant or applicant’s spouse

Part I . Select Premium Payment Option

Part II. Payor Information

METHOD OF PAYMENT FORM REQUIRED FORM – PLEASE RETURN PAGES 1 & 2

Applicant A

Applicant B

______________________ _____________________

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Part III. Account Information

Can

att

ach

void

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heck

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Complete the Following ONLY if Automated Bank Account Withdrawal is Chosen:This section is intended as authorization to debit your bank account. Complete bank account information below OR attach a copy of a voided check (Do NOT use a deposit slip)

• Payments cannot be postponed until a later date.• Payment from a third party, including any foundation, will not be accepted, except in certain pre-approved situations.• All refunds will be made to the applicant in the event of rejection, incomplete submission, overpayment, cancellation, etc.

Example: John Doe Check #1234 Street Address Town, City ZIP Code Date:___________ Pay to:__________________________________________ ________________________________________________Dollars Financial Institution Name & Address Memo____________ Signed By:____________________________

Account Holder Name

Account Number

Do NOT include the check # in the Routing or Account Number.

Routing/Transfer Number

Applicant A

$

1st or 15th

every_____months Insert 3, 6, or 12

Applicant B

$

1st or 15th

every_____months Insert 3, 6, or 12

|:123456789:| 12345678 ||■ 1234 ||■

. Initial Premium Payment (Select option #1 or #2)

✍ Initial premium amount (based on age at application date).......

1. Paper Check (submit signed check with application).................

2. Automated Bank Account Withdrawal...................................... Ongoing Premium Payments (Select option #1 or #2) 1. I want my payments automatically withdrawn from my bank account every month on (Circle date)....................................... 2. I will mail my premium to the company every 3, 6, or 12 months. (Monthly billing is not allowed. Select frequency of billing).......

When choosing automatic bank account withdrawal, MONEY WILL BE WITHDRAWN FROM YOUR ACCOUNT IMMEDIATELY UPON POLICY APPROVAL AND ISSUE. The first withdrawal date may be different from the monthly date selected for ongoing premiums. Depending on the amount of time elapsed between the policy date and the date the policy is placed inforce, the amount of the first ongoing withdrawal may exceed one modal premium and may occur on a date other than the policy date. The Proposed Insured/Insured will not receive premium billing notices while on this premium payment option. We CANNOT establish electronic payments from foreign banks. Ongoing premiums are due and will be automatically withdrawn from the account below on the same day of the month as the policy date or the date selected above. The policy date is determined at the time the policy is issued and can be found within the policy. Ongoing withdrawals will begin once the policy is placed inforce.

Part III. Account Information (continued) I authorize Omaha Insurance Company ("Omaha Ins. Co.") to withdraw funds from my account for the initial and/or monthlyrenewal premiums and understand that the amounts may differ. Premium shortages may result from a variety of causes, includingunderwriting adjustments. I authorize my financial institution to pay from my account to Omaha Ins. Co. any preauthorized bank accountwithdrawals. I agree that my financial institution shall be fully protected in honoring any such payment and that its rights and responsibilitiesregarding the payment shall be the same as if the payment were signed personally by me. I agree to notify the business in writing of anychanges in my account information. This authorization will be effective until I give you at least three business days' notice to cancel.If notice is given verbally, Omaha Ins. Co. may require written confirmation from me within 14 days after my verbal notice. Applicant A

✍_____________________________________________________Authorized Signature as Shown on Account

________________________________________________________Date

Applicant B

✍______________________________________________ Authorized Signature as Shown on Account

__________________________________________________Date

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Omaha Insurance Company A Mutual of Omaha Company

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

Save this notice! It may be important to you in the future.According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Omaha Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

Statement to Applicant by Issuer, Agent, Broker or Other Representative:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):

Applicant Applicant BAdditional benefits Additional benefits

No change in benefits, but lower premiums No change in benefits, but lower premiumsFewer benefits and lower premiums Fewer benefits and lower premiums

My plan has outpatient prescription drug coverage and I am enrolling in Part D

My plan has outpatient prescription drug coverage and I am enrolling in Part D

Disenrollment from a Medicare Advantage Plan Please explain reason for disenrollment

Disenrollment from a Medicare Advantage Plan Please explain reason for disenrollment

Other (please specify) Other (please specify)

If, you still wish to terminate your present policy or certificate and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keep it.

✗ __________________________________________________ _______________________Signature of Agent, Broker or Other Representative* DateOmaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175

Applicant Applicant BSignature Signature

Date Date

*Signature not required for direct response sales.

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IMPORTANT DOCUMENTS

LEAVE THE FOLLOWING REMAINING PAGES WITH CLIENT(S)

As part of the application process, the applicant has signed multiple forms. Applicant copies of these forms and client notifications on the following pages are to be given to the applicant(s) if applicable.

Replacement Notice If replacing, both you and the applicant must sign the customer copy of the replacement notice.

Premium Receipt / Notice of Information Practices

Provide applicant with completed and signed copy of application before submitting original application for processing.

Omaha Insurance Company A Mutual of Omaha Company

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

Save this notice! It may be important to you in the future.According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Omaha Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

Statement to Applicant by Issuer, Agent, Broker or Other Representative:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):

Applicant Applicant BAdditional benefits Additional benefits

No change in benefits, but lower premiums No change in benefits, but lower premiumsFewer benefits and lower premiums Fewer benefits and lower premiums

My plan has outpatient prescription drug coverage and I am enrolling in Part D

My plan has outpatient prescription drug coverage and I am enrolling in Part D

Disenrollment from a Medicare Advantage Plan Please explain reason for disenrollment

Disenrollment from a Medicare Advantage Plan Please explain reason for disenrollment

Other (please specify) Other (please specify)

If, you still wish to terminate your present policy or certificate and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the Company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy or certificate until you have received your new policy and are sure that you want to keep it.

✗ __________________________________________________ _______________________Signature of Agent, Broker or Other Representative* DateOmaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175

Applicant Applicant BSignature Signature

Date Date

*Signature not required for direct response sales.

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Omaha Insurance CompanyA Mutual of Omaha Company

Agent Information Form

Omaha Insurance Company P.O. Box 3608 Omaha, NE 68103

Agent Name ______________________________________________________

State Insurance Agent License Number ________________________________

Company _________________________________________________________

Insurance Sales Representative

Neither Omaha Insurance Company nor its agents are connected with any government agency.

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Omaha Insurance CompanyA Mutual of Omaha Company

All premiums must be made payable to Omaha Insurance Company.

Do not make check payable to the agent or leave the payee blank.

Applicant A Applicant B

Received from ___________________________________

this _____ day of _____________________ , __________

an application for Form_______________________Policy

and/or Riders ________________________________and

Check for ________________________________Dollars.

Received from ___________________________________

this _____ day of _____________________ , __________

an application for Form_______________________Policy

and/or Riders ________________________________and

Check for ________________________________Dollars.

✍ Agent ______________________________________ ✍ Agent ______________________________________

No insurance of any kind shall take effect until a policy is issued and delivered to the applicant, and the initial premium is paid, all during the life of the applicant. If no policy is issued, Omaha Insurance Company shall have no liability except to refund the initial premium to the applicant. This is a receipt of your application and initial premium.

In the course of properly underwriting and administering your insurance coverage, we will rely heavily on information provided by you. We may also collect information from others, such as medical professionals who have treated you, hospitals, other insurance companies, and consumer reporting agencies.

In certain circumstances, and in compliance with applicable law, we or our reinsurers may also release your personal or privileged information in our/their files, to third parties without your authorization. Upon request, you have the right to be told about and to see a copy of items of personal information about you which appear in our files, including information contained in investigative consumer reports. You also have the right to seek correction of personal information you believe to be inaccurate.

In compliance with applicable law, we or our reinsurers may also release information in our/their files, including information in an application, to other insurance companies to which you apply for life or health insurance or to which a claim is submitted.

So that there will be no question that the insurance benefits will be payable at the time a claim is made, we urge you to review your application carefully to be sure the answers are correct and complete.

THE ABOVE IS A GENERAL DESCRIPTION OF OUR INFORMATION PRACTICES. IF YOU WOULD LIKE TO RECEIVE A MORE DETAILED EXPLANATION OF THESE PRACTICES, PLEASE SEND YOUR REQUEST TO: OMAHA INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175.

Provide the completed premium receipt, if applicable, and notice to the applicant.

Premium Receipt

Notice of Information Practices

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