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					United of Omaha LIfe Insurance Company
A Mutual of Omaha Company
                                                                                                     Spontaneous.
2010 Medicare Supplement                                                                             fun!Fearless.
Insurance Plans                                                                                      Whether you’re six or sixty
                                                                                                     something, playing keeps you
Plans with coverage effective dates on and after June 1.                                             young-at-heart. The difference
                                                                                                     now, of course, is that you
                                                                                                     have adult responsibilities,
                                                                                                     including making sound
                                                                                                     financial decisions.
                                                                                                     You’ll probably enjoy playing,
                                                                                                     however you define it, even
                                                                                                     more when you feel you’ve
                                                                                                     got your bases covered.
                                                                                                     A Medicare supplement
                                                                                                     insurance policy from United
                                                                                                     of Omaha Life Insurance
                                                                                                     Company can help you attain
                                                                                                     that secure feeling.

                                                                                                     With a Medicare
                                                                                                     supplement, you
                                                                                                     • Keep your doctors and health
                                                                                                       care providers
                                                                                                     • See specialists without referrals
                                                                                                     • Receive benefits with no
                                                                                                       waiting period*
                                                                                                     • Enjoy guaranteed coverage
                                                                                                       for life*
                                                                                                     • Don’t pay a policy fee with
                                                                                                       our plan
                                                                                                     Add our helpful midwestern
                                                                                                     customer service staff and
                                                                                                     affordable premiums –
                                                                                                     including a discount for your
                                                                                                     eligible spouse or household
                                                                                                     resident – and you have the
                                                                                                     financial value and security
                                                                                                     you seek.
                                                                                                     *see details on back cover



                                                                                                     Underwritten by
                                                                                                     United of Omaha Life
                                                                                                     Insurance Company
                                                                                                     A Mutual of Omaha Company
                                                                                                     Mutual of Omaha Plaza

            We’ve got you covered.           GO PLAY!                                                Omaha, NE 68175
                                                                                                     mutualofomaha.com
                                                                                                     United of Omaha Life Insurance
                                                           Policy Forms: UM20-Plan A, UM23-Plan F,   Company is licensed nationwide
UC7232_GA                                                  UM24-Plan G                               except in NY.
Georgia
            Select the Medicare Supplement Plan that’s Right for You
                                            Medicare      Plan A            Plan F          Plan G
                                             Pays          Pays             Pays             Pays
Medicare Part A
Hospital Insurance*
Deductible                                  Nothing                        $1,100           $1,100
First 60 days                                100%
Coinsurance                                 All but        $275             $275             $275
 61-90 days                                  $275          a day            a day            a day
                                             a day
Coinsurance                                 All but        $550             $550             $550
 91-150 days                                 $550          a day            a day            a day
                                             a day
Extended Hospital Coverage                  Nothing       Eligible         Eligible         Eligible
 (up to an additional 365 days                           Expenses         Expenses         Expenses
 in your lifetime)
Benefit for Blood                            All but    Three pints      Three pints      Three pints
                                              three
                                              pints
Skilled Nursing Facility Care
First 20 days                                100%
Coinsurance                                 All but                         Up to            Up to
 21-100 days                                $137.50                        $137.50          $137.50
                                             a day                          a day            a day
Hospice Care
Outpatient Prescription Drugs                All but        $5               $5               $5
                                               $5
Inpatient Respite Care                       All but       5% of            5% of            5% of
                                              5%         Medicare’s       Medicare’s       Medicare’s
                                                         approved         approved         approved
                                                          amount           amount           amount
Medicare Part B
Medical Insurance*
Deductible                                  Nothing                         $155
Coinsurance                                  80%           20%              20%              20%
Excess Benefits                                                            100%             100%
                                                                           up to            up to
                                                                         Medicare’s       Medicare’s
                                                                            limit            limit
Benefit for Blood                            All but    Three pints      Three pints      Three pints
                                              three
                                              pints
Additional Benefit*
Emergency Care Received                     Nothing                           80% to           80% to
 Outside the U.S.                                                         lifetime max     lifetime max
                                                                            of $50,000       of $50,000
* Refer to the next page and your outline              Your Premium     Your Premium     Your Premium
  of coverage for more information.
                                                       $ ____________   $ ____________   $ ____________
Medicare Part A Hospital Coverage                           rate Medicare would have paid, subject to a lifetime
Medicare Part A hospital/skilled nursing facility care      maximum benefit of an additional 365 days.
eligible expenses include charges for semiprivate room      Benefit for Blood – Plans A, F and G pay Medicare’s
and board, general nursing and miscellaneous services       one calendar-year deductible for blood that is the cost
and supplies.                                               of the first three pints needed.
Deductible – Plans F and G pay the $1,100 inpatient         Skilled Nursing Facility Care Benefit
hospital deductible for each benefit period, which          Coinsurance – Plans F and G pay up to $137.50 a day
begins the first full day you’re hospitalized and ends      from the 21st through the 100th day during which you
when you haven’t been in a hospital or skilled nursing      receive skilled nursing care. You must enter a Medicare-
facility for 60 days in a row.                              certified skilled nursing facility within 30 days of being
Coinsurance – Plans A, F and G pay $275 a day when          hospitalized for at least three days.
you’re hospitalized from the 61st through the 90th day.     Hospice Care Benefit
And, when you’re in the hospital from the 91st day
through the 150th day, you receive $550 a day for each      Outpatient Prescription Drugs – Plans A, F and G pay
Lifetime Reserve day used.                                  $5 per prescription for outpatient prescription drugs
                                                            for pain and symptom management.
Extended Hospital Coverage – When you’re in the
hospital longer than 150 days during a benefit period,      Inpatient Respite Care – Plans A, F and G pay 5% of
and you’ve exhausted your 60 days of Medicare               the Medicare-approved amount for inpatient respite
Lifetime Reserve, Plans A, F and G pay the Medicare         care (short-term care given by another caregiver, so the
Part A eligible expenses for hospitalization, paid at the   usual caregiver can rest).




Medicare Part B Medical Coverage                            will be paid under a prospective payment system. If this
Medicare Part B eligible expenses include charges for       system is not used, then 20% of eligible expenses will
physicians’ services, hospital outpatient services and      be paid.
supplies, physical and speech therapy and ambulance         Excess Benefits – Your bill for Medicare Part B services
service.                                                    and supplies may exceed the Medicare eligible expense.
Deductible – Plan F pays the $155 calendar-year             When that occurs, Plans F and G pay 100% of the
deductible.                                                 difference, up to the charge limitation established
                                                            by Medicare.
Coinsurance – After the Medicare Part B deductible,
Plans A, F and G pay 20% of eligible expenses. For          Benefit for Blood – Plans A, F and G pay Medicare’s
hospital outpatient services, the copayment amount          one calendar-year deductible for blood that is the cost
                                                            of the first three pints needed.




Additional Benefit
Emergency Care Received Outside the U.S. – After            need because of a covered injury or illness beginning
you pay a $250 calendar-year deductible, Plans F and G      during the first 60 days of each trip up to a lifetime
pay you 80% of eligible expenses for health care you        maximum of $50,000.
Plan Overview                                                  • services for non-Medicare eligible expenses
                                                               • services for which no charge is made when there is
Your United of Omaha Medicare supplement
                                                                 no insurance
insurance policy helps pay some eligible expenses not
                                                               • loss or expense that is payable under any other
paid for by Medicare Part A and Medicare Part B.
                                                                 Medicare supplement insurance policy or certificate
There may be charges above what Medicare and
United of Omaha pay.                                           Medicare eligible expenses means charges of the kinds
                                                               covered by Medicare Parts A and B, to the extent
Your Medicare supplement will not pay for:
                                                               Medicare recognizes them as reasonable and medically
• any expense incurred before your policy date
                                                               necessary.
• hospital or skilled nursing facility confinement
  incurred during a Medicare Part A benefit period             Coinsurance is the portion of the eligible expense not
  that begins while this policy is not in force                paid by Medicare and paid by United of Omaha.
• expense paid for by Medicare




Features Give You More Peace of Mind                           Benefits are paid to you, your hospital or doctor.

You’re covered immediately. There is no waiting                You have 31 days from your renewal date to pay
period for preexisting conditions and benefits will be         your premium. Your policy will stay in force during
paid from the time your policy is in force.                    this 31-day grace period.

Your policy cannot be canceled. It will be renewed             You can’t be singled out for a rate increase, no
as long as the premiums are paid on time and the               matter how many times you receive benefits. Your
information is correct on your application.                    premium changes when the same premium change is
                                                               made on all in-force Medicare supplement policies of
Your Medicare supplement benefits will                         the same form issued to persons of your classification
automatically increase as Medicare deductibles and             in the same geographic area of your state. Your
coinsurance increase. Benefits are not paid for any            policy’s two-person household premium discount
expense paid by Medicare.                                      ends if the person you live with terminates his or her
                                                               policy or moves to a different residence.




                                                               A Mutual of Omaha company since 1926, United of
                                                               Omaha Life Insurance Company offers a diversified
                                                               portfolio of life insurance, fixed annuities and
                                                               Medicare supplement plans. When you own a
                                                               United of Omaha Medicare supplement, you get the
                                                               reputation, stability and power of Mutual of Omaha
                                                               and its affiliates, which have been providing quality
                                                               products and services since 1909.




This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information
on benefits, exceptions, limitations and reductions, please read your outline of coverage and your policy.
This is a solicitation of insurance and an insurance agent will contact you by telephone.
Neither United of Omaha Life Insurance Company nor its Medicare supplement insurance policies are connected with or
endorsed by the U.S. government or the federal Medicare program.
United of Omaha Life Insurance Company
A Mutual of Omaha Company
P.O. Box 3608 Omaha, Nebraska 68103-3608



Application Submission Checklist To United of Omaha For Medicare Supplement Coverage
– GEORGIA

THIS APPLICATION MUST BE USED TO WRITE UNITED OF OMAHA MEDICARE SUPPLEMENT PRODUCTS

o      Application
       1. Complete “Plan Information” Box.
       2. Refer to the Outline of Coverage for policy forms.
       3. Answer all questions in full.
       4. Sign and Date in all places indicated.
       5. Be sure to leave all applicable forms with the proposed insured.
       6. See reverse side of this page for additional detailed information.
o      Collect Premium Amount
	      •	 The	full	modal	premium	is	collected	at	the	time	of	application.
	      •	 Calculate	the	premium	based	on	age	at	time	of	application.
	      •	 Follow	instructions	on	page	1	of	Calculate Your Premium form (UC6582_0208) to calculate
           the premium.
o      Provide Client with Buyer’s Guide
o      Provide Client with Outline of Coverage
o      Complete Producer Information page
o      If applicable, complete the Authorization for Electronic Funds Transfer form (ACH/BSP form
       U7535_0409) and return with the completed application.
o      Provide Client with Conditional Receipt signed by agent (if applicable), and provide Client with
       Notice of Information Practices
o      Complete, sign and provide client with copy of the Authorization To Disclose Personal Information
       (HIPAA form U7566_0709). This form is NOT a requirement if applying during an Open Enrollment
       or Guaranteed Issue Period.
o      Complete Replacement Notice (U7563_GA) and leave a copy with the applicant (if applicable)
                           Please provide additional information and comments
                                in the space provided on the application.

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

BROKERAGE ONLY – Please list your “commission code” in the box on the first page of the
application. This will help avoid delay in commission payment.




                                                                                             UAP1088_GA
There are two parts to this application: One part is the general application. The other part includes necessary
administrative forms that you will need at time of sale.
1. Application – Agent Completes in Full: (please print)
   “Plan Information” Box
   •	 Policy	Form	
   •	 Requested	Effective	Date
  •	 Premium	Collected	(Amount)	-	Follow	instructions	on	page	1	of	Calculate	Your	Premium	form	
       (UC6582_0208)	to	calculate	the	premium.		Complete	the	form	for	Applicants	A	&	B	(if	applying)	return	with	
       the application.
  •	 Initial	Mode*	(A=Annual,	S=Semiannual,	Q=Quarterly,	or	ACH=Automatic	Funds	Withdraw)
  •	 Renewal	Premium	(Amount)
  •	 Renewal	Mode*	(A=Annual,	S=Semiannual,	Q=Quarterly,	or	B=Automatic	Funds	Withdraw)
       *Direct Monthly billing not available
   Section 1 “General Information”–
   •	 The	Residence	address	and	ZIP	code	are	indicated.	Alternate	address	for	billing	as	indicated	(when	applicable).
   •	 The	applicant’s	current	age	at	time	of	application.
   •	 The	applicant’s	Social	Security	number	as	indicated	from	applicant’s	Social	Security	Card.
   •	 For	applicants	already	covered	by	Medicare,	include	applicant’s	Medicare	number	on	the	application	as	
      indicated	from	the	applicant’s	Medicare	Health	Insurance	Card.	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.
   •	 The	applicant’s	current	Height	in	feet	and	inches	and	Weight	in	pounds.
   Sections 2 and 3 “Existing Coverage Information”–
   •	 Please	complete	all	questions	in	full.
   •	 If	the	applicant	is	not	covered	by	Medicare,	indicate	“Eligibility	Date”	and	“Date	of	Enrollment”.
   •	 List	all	individual	and	group	health	policies	held	by	the	applicant	in	the	appropriate	section	of	the	application.	
   •	 If	the	applicant	is	replacing	current	coverage	with	this	policy,	indicate	the	following	information.
      – Name of Company                           – Issue Date
   	 –	Policy/Certificate	Number	                 –	Termination/Disenrollment	Date
      – Plan                                      – Kind of Policy
   NOTE:	An	interviewer	may	call	to	verify/confirm	the	information	provided	on	the	application.
2. Administrative Forms
  Producer/Agent Information
  •	 Be	sure	to	include	your	Social	Security	number	and	commission	code.	
      NOTE: This information is necessary for the underwriting process and commission payment.
  •	 Include	your	telephone	number,	e-mail	address	and	FAX	number	for	contact	purposes.
    Authorization for Electronic Funds Transfer by United of Omaha Life Insurance Company (ACH/BSP) –
    If applicant chooses to pay premium by ACH/BSP, complete this form accurately and in its entirety and return with
    the application.
    •	 Option A	-	Pay	all	premiums	(1st	&	montly	renewals)	by	ACH/BSP	-	DO	NOT	submit	a	check	for	payment.
    •	 Option B	-	Pay	1st	month	by	paper	check	&	monthly	renewals	by	BSP	-	A	check	for	initial	monthly	premium	MUST	
         be submitted with the application
    •	 Option C -	Pay	1st	month	by	ACH	&	pay	renewals	by	direct	bill	(monthly	direct	billing	is	not	offered)	-	
         DO	NOT	submit	a	check	for	initial	premium	payment.
  Conditional Receipt and Notice of Information Practices
  •	 Complete	and	sign	the	receipt	(if	applicable),	detach	entire	page	and	leave	with	applicant.
  Authorization To Disclose Personal Information (HIPAA)
  •	 If client is NOT applying during an Open	Enrollment	or	Guaranteed	Issue	Period,	completing	the	Authorization
       To	Disclose	Personal	Information	form	IS a requirement. Please have the applicant read	the	form,	fill	in	
       required	information,	sign,	date	and	leave a copy of the completed and signed form with applicant.
  •	 If	client	IS	applying	during	an	Open	Enrollment	or	Guaranteed	Issue	Period,	completing	the	Authorization
       To	Disclose	Personal	Information	form is NOT a requirement.
  Replacement Notice – complete if applicable
  •	 Complete	form including signature and date.
  • Leave	a	copy	with	applicant	(if	applicable).
  State – Specific Forms – complete if applicable
  •	 Be	sure	to	include	all	state	appropriate	forms.
                                                                                               Group number (if applicable):_____________________


United of Omaha Life Insurance Company
Application For Medicare Supplement Coverage
Mgr./Commission Code (Required Field For Brokerage) District Sales Manager/Assoc. Marketer             Application Reviewed By
5D
 PLAN INFORMATION (to be completed by Producer)

 NOTE: For ALL sections, ONLY complete the Applicant B information if to be insured.
APPLICANT                                                                   APPLICANT B
Policy Form                                                                 Policy Form

Requested Effective Date                                                    Requested Effective Date
Premium Collected $                                                         Premium Collected $
Initial Mode A, S, Q, ACH                                                   Initial Mode A, S, Q, ACH
Renewal $                                                                   Renewal $

Renewal Mode A, S, Q, B            (monthly not available)                  Renewal Mode A, S, Q, B,           (monthly not available)

1.      PLEASE READ THE FOLLOWING CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY.
Applicant                                                                   Applicant B
Name (First/Middle/Last)                                                    Name (First/Middle/Last)

Residence Address                                                           Residence Address (if different from Applicant’s)

City                                                                        City

State                                              ZIP                      State                                                ZIP

Mailing Address (if different from residence address)                       Mailing Address (if different from residence address)

City                                                                        City

State                                              ZIP                      State                                                ZIP


Home Phone No (_______)____________________________                         Home Phone No (_______)____________________________
               (area code)                                                                 (area code)
                                         			/									/
Current Age _________ Date of Birth___________________                                                               		/									/
                                                                            Current Age _________ Date of Birth___________________
                                      mo      day       yr                                                        mo     day       yr
Male                          Female                                        Male                          Female

Social Security No                                                          Social Security No

Medicare Health Insurance Card Number (if known)                            Medicare Health Insurance Card Number (if known)

E-mail Address                                                              E-mail Address

Height                                    Weight                            Height                                    Weight
Ft ________ In ________                   Lbs __________                    Ft ________ In ________                   Lbs __________




UA5910-09              United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                                   1
2.   PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
1. Have you received a copy of the Guide to Health Insurance for People with Medicare and the                 Applicant    Applicant B
   Outline of Coverage?                                                                                     Yes  No     Yes  No 
2. Have you used tobacco in any form in the past 12 months?                                                 Yes  No     Yes  No 
To the Best of Your Knowledge:
1. Are you covered under Medicare Part A?                                                                   Yes  No     Yes  No 
                                                     			/									/        			/									/
    If “YES,” what is your Part A effective date? _______________ / _____________________
                                                  Applicant                 Applicant B
                                                   			/									/         			/									/
     If “NO,” what is your eligibility date? ___________________ / ______________________
                                            Applicant                      Applicant B
2. Are you covered under Medicare Part B?                                                                   Yes  No     Yes  No 
                                                    			/									/        			/									/
   If “YES,” what is your Part B effective date? ______________ /_______________________
                                                   Applicant             Applicant B
                                                   			/									/        			/									/
     If “NO,” indicate date you plan to enroll. ________________ /_______________________
                                                Applicant                Applicant B
3. Did you turn age 65 in the last six months?                                                              Yes  No     Yes  No 
4. Did you enroll in Medicare Part B in the last six months?                                                Yes  No     Yes  No 
                                                			/									/         			/									/
   If “YES,” indicate your effective date. ___________________ /_______________________
                                            Applicant                    Applicant B

  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 that you had certain rights to buy such a policy, 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.
3.   FOR YOUR PROTECTION, the National Association of Insurance Commissioners requests that we ask the
     following questions about insurance policies or certificates you may have.
To the Best of Your Knowledge:                                                                                Applicant    Applicant B
1. Are you applying during a guaranteed issue period?                                                       Yes  No     Yes  No 
   (NOTE: If the answer above is “YES,” please attach proof of eligibility.)
2. Do you have another Medicare supplement or Medicare select insurance policy or
   certificate in force?                                                                                    Yes  No     Yes  No 
   (a) If “YES,” with what company, and what plan do you have?
Applicant                                                                 Applicant B
Name of Company                                                           Name of Company

Policy/Certificate Number                                                 Policy/Certificate Number

Plan                                                                      Plan

Issue Date                                                             Issue Date
                   			/									/                                                            			/									/
     (b) If “YES,” do you intend to replace your current Medicare supplement policy/certificate with
         this policy?                                                                                       Yes  No     Yes  No 
                                                   			/									/             			/									/
     (c) If “YES,” indicate termination date. ________________ / ________________________
                                              Applicant                  Applicant B
    (d) If “YES,” have you received a copy of the replacement notice?                               Yes  No             Yes  No 
If you have had any other Medicare plan coverage as referenced below, not to include
Medicare supplement, please complete questions (a-g) below. If not, skip to question #4.
3. If you had coverage from any Medicare plan other than original Medicare within the past
    63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your
    start and end dates below. If you are still covered under this plan, leave “END” blank.
                			/									/        			/									/            			/									/
    START ______________ END ____________ / START ____________ END ____________      			/									/
             Applicant                                            Applicant B
     (a) If you are still covered under the Medicare plan, do you intend to replace your current
         coverage with this new Medicare supplement policy?                                      Yes  No  Yes  No 
     (b) If “YES,” have you received a copy of the replacement notice?                           Yes  No  Yes  No 
     (c) Reason for termination/disenrollment? _______________________________ / _________________________________
                                                   Applicant                                  Applicant B
                                                           			/									/                    			/									/
     (d) Planned date of termination/disenrollment? ___________________________ / _________________________________
                                                          Applicant                           Applicant B

UA5910-09                United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                           2
                                                                                                             Applicant        Applicant B
   (e) Was this your first time in this type of Medicare plan?                                          Yes  No             Yes  No 
   (f) Did you drop a Medicare supplement or Medicare select policy/certificate to enroll in this
       Medicare plan?                                                                                   Yes  No             Yes  No 
   (g) Is your former Medicare supplement or Medicare select policy/certificate still available?        Yes  No             Yes  No 
4. Have you had coverage under any other health insurance within the past 63 days?                      Yes  No             Yes  No 
   (For example, an employer, union, or individual non-Medicare supplement plan.)
   (a) If “YES,” with what company and what kind of policy? (List below.)
Applicant                                                            Applicant B
Name of Company                    Kind of Policy                    Name of Company                         Kind of Policy


   (b) What are your dates of coverage under the other policy? If you are still covered under this plan, leave “END” blank.
                   			/									/                 			/									/                      			/									/
       START _____________________ END ___________________ / START ____________________ END ___________________      			/									/
               Applicant                                                         Applicant B
   (c) Reason for termination/disenrollment? ________________________________ / ________________________________
                                                Applicant                                      Applicant B
                                                           			/									/                   			/									/
   (d) Planned date of termination/disenrollment? ____________________________ / ________________________________
                                                      Applicant                                Applicant B

5. Are you covered for medical assistance through the state Medicaid program?                Yes  No                        Yes  No 
   (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,”
   (a) Will Medicaid pay your premiums for this Medicare supplement policy?                  Yes  No                        Yes  No 
   (b) Do you receive any benefits from Medicaid OTHER THAN payment toward your
        Medicare Part B premium?                                                             Yes  No                        Yes  No 
6. Producers shall list any other health insurance policies they have sold to the applicant.
   (a) List policies sold which are still in force.
Applicant                                                            Applicant B
Name of Company                                                      Name of Company

Policy/Certificate Number                                            Policy/Certificate Number

Description of Benefits                                              Description of Benefits

Effective Date of Coverage                                           Effective Date of Coverage


   (b) List policies sold in the past five (5) years which are no longer in force.
Applicant                                                            Applicant B
Name of Company                                                      Name of Company

Policy/Certificate Number                                            Policy/Certificate Number

Description of Benefits                                              Description of Benefits

Effective Date of Coverage                                           Effective Date of Coverage




UA5910-09            United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                                    3
 If you are applying during Open Enrollment or a Guaranteed Issue period, SKIP SECTION 4 and GO TO SECTION 5.
4. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS. Make sure all questions are answered by each applicant.
     If either you or Applicant B answer “YES” to any of the following questions 1-14, that person is not eligible for coverage.
 To the Best of Your Knowledge:                                                                  APPLICANT APPLICANT B
  1. Are you currently hospitalized or confined to a nursing facility; or, are you bedridden or
     confined to a wheelchair?                                                                         Yes      No        Yes     No
  2. Within the last ten years have you been diagnosed with or treated for emphysema, Chronic
     Obstructive Pulmonary Disease (COPD) or other chronic pulmonary disorders?                        Yes      No        Yes     No
  3. Within the last ten years have you been diagnosed with or treated for Parkinson’s Disease,
     Systemic Lupus, Myasthenia Gravis, Multiple or Lateral Sclerosis, Osteoporosis with fractures,
     Cirrhosis or kidney disease requiring dialysis?                                                   Yes      No        Yes     No
  4. Within the last ten years have you been diagnosed with or treated for Alzheimer’s Disease,
     Senile Dementia, or any other cognitive disorder?                                                 Yes      No        Yes     No
  5. Within the last ten years have you been diagnosed with or treated for Acquired Immune
     Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?                                         Yes      No        Yes     No
  6. If you have diabetes, do you have any of the following conditions: diabetic retinopathy,
     peripheral vascular disease, neuropathy, any heart condition (including high blood pressure)
     or kidney disease? If you do not have diabetes, this question should be answered “NO”.            Yes      No        Yes     No
  7. Do you have diabetes that has ever required more than 50 units of insulin daily?                  Yes      No        Yes     No
  8. Within the past two years have you been treated for or been advised by a physician to
     have treatment for internal cancer, alcoholism or drug abuse, mental or nervous disorder
     requiring psychiatric care or have you had any amputation caused by disease?                      Yes      No        Yes     No
  9. Within the past two years have you been treated for or been advised by a physician to have
     treatment for heart attack, heart, coronary or carotid artery disease (not including high blood
     pressure), peripheral vascular disease, congestive heart failure or enlarged heart, stroke,
     transient ischemic attacks (TIA) or heart rhythm disorders?                                       Yes      No        Yes     No
 10. Within the past two years have you been treated for degenerative bone disease, crippling/
     disabling or rheumatoid arthritis or have you been advised to have a joint replacement?           Yes      No        Yes     No
 11. Have you been advised by a physician that surgery may be required within the next 12
     months for cataracts?                                                                             Yes      No        Yes     No
 12. Have you been advised by a physician to have surgery, medical tests, treatment or therapy
     that has not been performed?                                                                      Yes      No        Yes     No
 13. Have you been hospital confined three or more times in the last two years?                        Yes      No        Yes     No
 14. Have you had an organ transplant or been advised by a physician to have an organ transplant?      Yes      No        Yes     No
 15. Are you taking or have you taken any prescription or over-the-counter medications within
     the past 12 months? If “YES,” please list the drug and the condition in the following table.      Yes      No        Yes     No
Applicant (please attach a separate sheet if needed)                                Applicant B (please attach a separate sheet if needed)
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition


UA5910-09             United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                               4
 5.    HOUSEHOLD DISCOUNT INFORMATION – Please Answer BOTH Questions 1 & 2 In This Section.
 You may be eligible for a policy with a lower rate based on your answers to the statements in        Applicant   Applicant B
 this section.
 1. I have continuously resided with another person for the last 12 months or are married and
      they are also applying for this coverage. If “YES,” please complete the information regarding
      Relationship to Applicant below, unless you AND Applicant B are applying for coverage
      on THIS application then do not complete the Relationship to Applicant information.           Yes    No     Yes   No
 2.    I have continuously resided with another person for the last 12 months or are married and
       they have an existing Medicare supplement policy or certificate with Mutual of Omaha
       Insurance Company or United World Life Insurance Company or United of Omaha Life
       Insurance Company. If you answer “YES,” to this question, please complete the
       information regarding Relationship to Applicant below.                                      Yes    No
Relationship to Applicant:
First Name


Last Name


Street Address


City                                    State            ZIP


Policy/Certificate Number




UA5910-09            United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                     5
6.   PLEASE READ AND SIGN BELOW
                                    IMPORTANT STATEMENTS TO BE READ BY APPLICANT
     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 your state to provide advice concerning your purchase of Medicare supplement
     insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare
     Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

 I wish to apply for a Medicare supplement insurance policy. I represent that my answers and statements on this application are
 true and complete. I understand that, upon acceptance of the completed application, each applicant will receive a separate policy.
 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 United of Omaha Life Insurance Company.


 Dated at __________________________, on __________________, _____                 _________________________________________
          City                         State    Month              Day    Year     Applicant’s Signature


 Dated at __________________________, on __________________, _____                 _________________________________________
            City                       State    Month              Day    Year     Applicant B’s Signature (if applying)

 Premium Must Accompany Application
 I/We certify that during an interview with the proposed applicant, I/we have truly and accurately recorded in the application the
 information supplied by the applicant.

 ____________________________________________________ ________________________________________________
 (Signature of Licensed Producer)                                        (Signature of Licensed Producer)


 ____________________________________________________ ________________________________________________
 PRODUCER STAMP                                                          PRODUCER STAMP




UA5910-09            United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                               6
ADDITIONAL INFORMATION: PART 4 - CON’T. HEALTH/MEDICAL QUESTIONS - Question #15
Applicant (please attach a separate sheet if needed)                                 Applicant B (please attach a separate sheet if needed)
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition
                                                       Medication Name (copy off
                                                           pharmacy label)
                                                       Date Originally Prescribed
                                                         Frequency and Dosage
                                                         Diagnosis/Condition

 SECTION FOR ADDITIONAL COMMENTS
Applicant (please attach a separate sheet if needed)                 Applicant B (please attach a separate sheet if needed)




UA5910-09             United of Omaha Life Insurance Company • P.O. Box 3608 • Omaha, Nebraska 68103-3608                                7
United of Omaha Life Insurance Company
A Mutual of Omaha Company

Calculate Your Premium
Medicare Supplement

Medicare Supplement Plan _____
Before you begin: If you’re not in your open enrollment or guarantee issue period, please go to page 2 to
determine your eligibility for coverage.

 Line   Steps                                             Example                        Applicant’s   Applicant B’s
                                                          Rate displayed is used for     Premium       Premium
                                                          calculation purposes only.
  #1    Premium                                           $128.52
        Write	in	your	Med	supp	plan’s	premium	from	
        the Outline of Coverage provided.
  #2    Household Discount                                $128.52	x	.93	=	$119.52	
        Are you eligible to receive a household
        discount?                                         In	this	example,	the	person	
        If	yes,	multiply	line	#1	by	.93.		                qualifies	for	the	household	
        If	no,	enter	the	amount	from	line	#1.             discount.
  #3    Rate Adjustment
        If you’re in your open enrollment or guarantee    $119.52	x	1.20	=	$143.42
        issue period, skip to step #4.
        On	page	2,	locate	your	height,	then	weight.	      Person’s	weight	is	in	the	
                                                          Class	II	20%	column.
        If	your	weight	is	in	the	Standard	column,	
        enter	the	amount	from	line	#2.

        If	your	weight	is	in	the	Class	I	or	II	column,	
        multiply	the	amount	on	line	#2	by:	
        1.10	if	in	10%	column
        1.20	if	in	20%	column
  #4    Payment Options
        Your	monthly	payment	is	your	last	premium	        $143.42 monthly payment
        entered	(line	#2	or	#3).	
        To	determine	other	payment	schedules,	
        multiply	your	monthly	premium	by:
        3	to	pay	4	times	a	year	(quarterly)               $430.26	quarterly	payment
        6	to	pay	twice	a	year	(semiannually)              $860.52	semiannual	payment
        12	to	pay	once	a	year	(annually)                  $1,721.04	annual	payment




                                             Complete and return with application




                                                              Page 1                                      UC6582_0208
Height and Weight Chart
Eligibility
Find	your	height	in	the	left-hand	column	and	look	across	the	row	to	find	your	weight.		If	your	weight	is	in	the	Decline	
column,	we’re	sorry,	you’re	not	eligible	for	coverage	at	this	time.
Rate Adjustment
The	column	heading	above	your	weight	will	indicate	your	appropriate	rate	adjustment,	if	any	(risk	class).

                       Decline         Class I (10%)       Standard        Class I (10%)     Class II (20%)        Decline
     Height             Weight            Weight            Weight             Weight            Weight            Weight
      4' 2''             < 54            54	–	60          61	–	110           111	–	128         129	–	145            146 +
      4' 3''             < 56             56 – 62          63 – 114          115 – 133         134 – 151            152 +
      4' 4''             <	58            58	–	65          66	–	119           120	–	138         139	–	157            158	+	
     4' 5''              <	60            60	–	67          68	–	123           124 – 143         144 – 163            164 +
      4' 6''             < 63            63	–	70          71	–	128           129	–	149         150	–	170            171	+	
     4'	7''              < 65            65	–	73          74	–	133           134 – 154         155	–	176            177	+	
     4'	8''              <	67            67	–	75          76	–	138           139	–	160         161	–	182            183	+	
     4'	9''              <	70            70	–	78          79	–	143           144 – 166         167	–	189            190	+	
     4'	10''             <	72            72	–	81          82	–	148           149	–	172         173	–	196            197	+	
     4' 11''             <	75            75	–	84          85	–	153           154	–	178         179	–	202            203	+	
      5'	0''             <	77            77	–	87          88	–	158           159	–	184         185	–	209            210	+	
      5' 1''             <	80            80	–	89          90	–	164           165	–	190         191	–	216            217	+	
      5' 2''             <	83            83	–	92          93	–	169           170	–	196         197	–	224            225 +
      5' 3''             <	85            85	–	95          96	–	175           176	–	203         204	–	231            232 +
      5' 4''             <	88            88	–	99          100	–	180          181	–	209         210	–	238            239	+	
      5' 5''             <	91           91	–	102          103	–	186          187	–	216         217	–	246            247	+	
      5' 6''             <	93           93	–	105          106	–	192          193	–	223         224 – 254            255 +
      5'	7''             <	96           96	–	108          109	–	197          198	–	229         230	–	261            262 +
      5'	8''             <	99            99	–	111         112	–	203          204	–	236         237	–	269            270	+	
      5'	9''            <	102           102	–	115         116	–	209          210	–	243         244	–	277            278	+	
     5'	10''            <	105           105	–	118         119	–	216          217	–	250         251	–	285            286	+	
     5' 11''            <	108           108	–	121         122 – 222          223	–	258         259	–	293            294	+	
      6'	0''            < 111           111 – 125         126	–	228          229	–	265         266	–	302            303	+	
      6' 1''            < 114           114	–	128         129	–	234          235	–	272         273	–	310            311 +
      6' 2''            <	117           117	–	132         133 – 241          242	–	280         281	–	319            320	+	
      6' 3''            < 121           121 – 136         137	–	248          249	–	288         289	–	328            329	+	
      6' 4''            < 124           124	–	139         140	–	254          255	–	295         296	–	336            337	+	
      6' 5''            <	127           127	–	143         144 – 261          262	–	303         304	–	345            346 +
      6' 6''            <	130           130	–	147         148	–	268          269	–	311         312 – 354            355 +
      6'	7''            < 134           134	–	150         151	–	275          276	–	319         320	–	363            364 +
      6'	8''            <	137           137	–	154         155	–	282          283	–	327         328	–	373            374	+	
      6'	9''            <	140           140	–	158         159	–	289          290	–	335         336	–	382            383	+	
     6'	10''            < 144           144 – 162         163	–	296          297	–	344         345	–	392            393	+	
     6' 11''            <	147           147	–	166         167	–	303          304	–	352         353	–	401            402	+	
      7'	0''            < 151           151	–	170         171	–	311          312 – 361         362 – 411            412 +
      7'	1''            < 155           155	–	174         175	–	318          319	–	369         370	–	421            422 +
      7'	2''            <	158           158	–	178         179	–	326          327	–	378         379	–	431            432 +
      7'	3''            < 162           162	–	183         184	–	333          334	–	387         388	–	441            442 +
      7'	4''            < 166           166	–	187         188	–	341          342	–	396         397	–	451            452 +

Medicare supplement insurance is underwritten by
United of Omaha Life Insurance Company
A Mutual of Omaha Company
Mutual of Omaha Plaza
Omaha, Nebraska 68175
mutualofomaha.com
Policy forms UM1, UM2, UM3, UM4, UM5, UM6, UM7, UM8, UM9 or state equivalent.
                                                      Page 2                                                         UC6582_0208
United of Omaha Life Insurance Company
A Mutual of Omaha Company

Policy Delivery
Mail	policy/policies	to:
    a)		Applicant	                     Producer 
    b)		Applicant	B	                   Producer 


Producer(s) Information

Producer Name	_________________________________________         Social Security No	____________________________
                                                                                          5D
Comm.	%	Share	________ 	 Producer	Phone	No	(____)	____________________ Commission Code	_____________________
Producer	E-mail	Address	__________________________________                                    @	____________________________________________
Producer	FAX	Number	 	____________________________________


Producer Name	_________________________________________                                           Social Security No	____________________________
Comm.	%	Share	________ 	 Producer	Phone	No	(____)	____________________ Commission Code	_____________________
Producer	E-mail	Address	__________________________________                                    @	____________________________________________
Producer	FAX	Number	 	____________________________________


Producer To Complete Only If Premium Is To Be Paid With A Business Check/Account
Initial Payment
Is	the	applicant:	                                                                                                                                              Yes	    No
	   (a)	 unemployed?...............................................................................................................................................    
	   (b)	 employed,	but	not	working	for	the	business	that	is	paying	the	premium? .....................................................                                  
	   (c)	 the	business	owner	or	spouse	of	the	business	owner? .................................................................................                         
If	(a),	(b),	or	(c)	is	“Yes,”	the	premium	can	be	paid	with	a	business	check/account.

Renewal Payment
Is	the	applicant:	                                                                                                                                              Yes	    No
	   (a)	 unemployed?...............................................................................................................................................    
	   (b)	 employed,	but	not	working	for	the	business	that	is	paying	the	premium? .....................................................                                  
	   (c)	 the	business	owner	or	spouse	of	the	business	owner? .................................................................................                         
If	(a),	(b),	or	(c)	is	“Yes,”	the	premium	can	be	paid	with	a	business	check/account.
Instructions for Completion of Authorization for Electronic Funds Transfer (ACH/BSP) Form
                    Account Holder Name
                                                                                                          Check Number




                    {




                                                                                                           {
                       John Doe                                                                      Check #1234
                       Street Address
                       Town, City Zip code                                                Date:_________________

                       Pay to: __________________________________________________________________

                       ___________________________________________________________________ Dollars
                       Bank Name
                       & Address
                       Memo_________________             Signed By: _________________________________
                      |:123456789:|       12345678 ||■     1234 ||■




                                          {
                      {

                                                         {
                                                                 Check Number
                      Bank Routing/       Bank Account    (if shown at bottom, may be
                                                                                            Do NOT include the check number as part
                     Transfer Number        Number       before or after the account #)     of either the Routing or Account Number.


The applicant may select one of three payment options indicated on the back side of this form. Instructions for each
option are listed below. With each option, the form must be signed and dated.
    Option A: Pay all premiums (1st month and monthly renewals) by Electronic Funds Transfer (EFT).
    Automated Clearing House (ACH) is used for initial payment and Bank Service Plan (BSP) is used for renewal payments.
    When choosing to pay both the initial and monthly renewals by EFT, the applicant must complete the form and
    submit it with the application. DO NOT submit a signed check for payment under this option. To avoid potential
    delays in processing, submit a voided check and complete the account information (routing/account numbers,
    name of financial institution) on the form.
    Option B: Pay 1st month by paper check and monthly renewals by BSP
    When choosing to pay the initial premium via paper check and the monthly renewals by BSP, the applicant must
    complete the form and submit it with the application. A signed check for the initial monthly premium must be
    submitted with the application.
    Option C: Pay 1st month by ACH and pay renewals by direct bill (monthly direct billing is not offered)
    When choosing to pay the initial premium by ACH and renewal premiums by direct billing (quarterly,
    semiannually, or annually), the applicant must complete the form and submit it with the application. DO NOT
    submit a signed check for the initial premium payment under this option. To avoid potential delays in processing,
    submit a voided check and complete the account information (routing/account number, name of financial
    institution) on the form.

    When choosing to pay initial premium by ACH, money will be withdrawn on the date the application is processed.
    This may be different from the monthly withdraw date selected for renewal premiums.
Payments cannot be postponed until a later date.
Payment from a third party, including any foundation, cannot be accepted.
All refunds will be made to the applicant in the event of rejection, incomplete submission, overpayment, cancellation, etc.
Please complete the Electronic Funds Transfer form accurately and in its entirety, making sure that all required
information is correct and complete on your Electronic Funds Transfer form prior to submission. In addition, please
make sure that the premium amount is filled in on the Electronic Funds Transfer form so we can initiate a timely and
accurate withdrawal from your client’s bank account.
An example of how to find correct Routing and Account Numbers on your clients’ checks is included at the top of this
form. Do not include the check number as part of either the Routing or Account Number. The applicant’s bank name
is normally included above the Memo line on the check.

                                                                                                                                 U7535_0409
United of Omaha Life Insurance Company                                                                                                          Please refer to instructions
A Mutual of Omaha Company                                                                                                                       on	the	Front	of	this	form.


Authorization for Electronic Funds Transfer (ACH/BSP)
This form is intended as authorization to debit your account. Please complete initial and renewal premium payment
information below.                                                                        Applicant A Applicant B
Medicare Supplement Premium Payment Options:                                                                                                     YES     NO YES         NO
A. Pay premiums (1st month and monthly renewals) by Electronic Funds Transfer                                                                            	 	 
   (ACH is used for initial payment and BSP is used for renewal payments.)
B. Pay 1st premium by signed paper check and pay monthly renewals by BSP                                                                                 	 	 
C. Pay initial premium by ACH and pay renewals by direct bill (monthly direct billing is not offered)                                                    	 	 
    • If choosing Options A or C, list amount of initial premium withdrawal . . . . . . . . . . . . . . . . $ ________ $ ________
    • If choosing Options A or B,
      select a withdrawal date for monthly renewal payments (circle one) . . . . . . . . . . . . . . . . . . . . 1st or 15th 1st or 15th
    • Is a Business Account being used to pay premiums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                	 	 
    • If yes, is the applicant:
      (a) Unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       	 	 
      (b) Employed, but not working for the business that is paying the premium . . . . . . . . . . . . .                                                	 	 
      (c) The business owner or spouse of the business owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                 	 	 
             If (A), (B), or (C) are “Yes,” premiums CAN be paid with a business account.
Applicant A                                                                                    Applicant B
    Complete the information below. To avoid potential delays in processing, submit a copy of a voided check.
Account Type (check one):                   Checking               Savings                   Account Type (check one):                     Checking        Savings
_______________________________________________                                                ______________________________________________
Name of Financial Institution                                                                  Name of Financial Institution

_______________________________________________                                                ______________________________________________
Routing Number (first 9 digits on lower left side of check)                                    Routing Number (first 9 digits on the lower left side of check)

_______________________________________________                                                ______________________________________________
Account Number                                                                                 Account Number
(Do NOT use Debit or Credit Card account numbers)                                              (Do NOT use Debit or Credit Card account numbers)

_______________________________________________                                                ______________________________________________
Name as Shown on Account                                                                       Name as Shown on Account

       IMPORTANT: Withdrawal date of the initial premium payment will occur when the application is
                  processed and may be different than the monthly withdrawal date selected above.

I authorize United of Omaha Life Insurance Company (“United of Omaha”) to withdraw funds from my account for my initial
and/or monthly renewal premiums and understand that the amounts may differ. I also authorize United of Omaha to collect
any premium(s) due by bank draft withdrawal. Premium shortages may result from a variety of causes, including underwriting
adjustments. I authorize you, my financial institution, to pay from my account any checks, drafts or preauthorized electronic
fund transfers from my account to United of Omaha. Your rights with each charge will be the same as if personally paid by me.
The authorization will be effective until I give you at least three‐ business days’ notice to cancel it. If notice is given verbally, you
may require written confirmation from me within 14 days after my verbal notice.

_______________________________________________                                                ______________________________________________
Authorized Signature as Shown on Account                                                       Authorized Signature as Shown on Account

_______________________________________________                                                ______________________________________________
Date                                                                                           Date                                                           U7535_0409
United of Omaha Life Insurance Company
A Mutual of Omaha Company

Conditional Receipt
Check or Money Order Application
All	premiums	must	be	made	payable	to	the	United	of	Omaha	Life	Insurance	Company.
Do not make check or money order payable to the agent or leave the payee blank.
Applicant                                                     Applicant B

Received of                                                   Received of
this                                     day of               this                                     day of
                                    ,	                                                            ,	
an	application	for	Form	                             Policy   an	application	for	Form	                             Policy
and/or	Riders	                                         and and/or	Riders	                                            and
Check	or	Money	Order	for	                           Dollars. Check	or	Money	Order	for	                            Dollars.

Should the Company decline to issue the insurance             Should the Company decline to issue the insurance
applied	for,	I	hereby	agree	to	return	the	above	sum	to	the	   applied	for,	I	hereby	agree	to	return	the	above	sum	to	the	
applicant.                                                    applicant.
Agent                                                         Agent

NOTICE TO APPLICANT: 	Eligibility	for	the	health	and	accident	insurance	applied	for	is	conditional	upon	all	of	
the	following:
(a)	 payment	of	the	full,	initial	premium;	(b)	written	application;	(c)	satisfying	the	Company’s	underwriting	standards.
If you are not eligible, no insurance or temporary or interim insurance of any kind will be effective.
                       Complete Receipt in full and leave with applicant at time of application.


United of Omaha Life Insurance Company - Notice of Information Practices
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: UNITED OF OMAHA LIFE
INSURANCE COMPANY, DIRECTOR OF INDIVIDUAL UNDERWRITING, MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175.
                                            Give this notice to the applicant.
United of Omaha Life Insurance Company


Authorization To Disclose Personal Information To United of Omaha Life Insurance Company
                                                           Meanings of Terms
“Medical Persons and Entities” means: all	physicians,	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.
“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.
“Psychotherapy Notes” means:	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.
  “Specified Companies” means:
      •	 The	group	of	companies	which	presently	includes	Mutual	of	Omaha	Insurance	Company,	United	of	Omaha	Life	
            Insurance	Company,	United	World	Life	Insurance	Company,	Companion	Life	Insurance	Company,	additional	
            companies which may become part of this group of companies and their successors.
      •	 Other	persons	and	entities	which	act	on	behalf	of	those	companies	to	provide	services	to	them.
                                                       Authorization to Disclose
I	authorize	the	Medical	Persons	and	Entities,	the	Specified	Companies,	employers,	consumer	reporting	agencies	and	other	
insurance	companies	to	disclose	Personal	Information	about	me	to	United	of	Omaha	Life	Insurance	Company.
                                                               Purposes
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.
                                                      Potential for Redisclosure
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.
                                                             Failure to Sign
I	understand	that	I	may	refuse	to	sign	this	authorization.	I	realize	that	if	I	refuse	to	sign,	the	insurance	for	which	I	am	applying	
will not be issued.
                                                      Expiration and Revocation
Unless	revoked	earlier,	this	authorization	will	remain	in	effect	for	24	months	from	the	date	I	sign	it.	I	understand	that	I	may	
revoke	this	authorization	at	any	time,	by	written	notice	to:
                                                    ATTN:	Individual	Underwriting
                                              United	of	Omaha	Life	Insurance	Company
                                                        Mutual of Omaha Plaza
                                                        Omaha,	NE	68175-0001
I	realize	that	my	right	to	revoke	this	authorization	is	limited	to	the	extent	that	United	of	Omaha	Life	Insurance	Company	has	
taken	action	in	reliance	on	the	authorization	or	the	law	allows	United	of	Omaha	Life	Insurance	Company	to	contest	the	issuance	
of the policy or a claim under the policy.
                                                                  Copy
I understand that I will receive a copy of the signed authorization. A copy of this authorization is as effective as the original.
                                                         Names and Signatures
Name(s)	used	for	medical	records	(if	different	than	the	name(s)	below):	 ______________________________________________
___________________________________________________________________________________________________________
 Applicant                                                         Applicant B
 Printed Name of Proposed Applicant                                Printed Name of Proposed Applicant

 Signature of Proposed Applicant                                   Signature of Proposed Applicant

 Date                                                              Date


U7566_0709           THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS
United of Omaha Life Insurance 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	United	of	Omaha	Life	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 B
        Additional benefits                                                  Additional benefits
        No	change	in	benefits,	but	lower	premiums                            No	change	in	benefits,	but	lower	premiums
        Fewer	benefits	and	lower	premiums                                    Fewer	benefits	and	lower	premiums
        My plan has outpatient prescription drug coverage                    My plan has outpatient prescription drug coverage and I
        and I am enrolling in Part D                                         am enrolling in Part D
        Disenrollment from a Medicare Advantage Plan Please                  Disenrollment from a Medicare Advantage Plan Please
        explain reason for disenrollment                                     explain reason for disenrollment
        Other	(please	specify)___________________________                    Other	(please	specify)_____________________________



1.	 If	a	Medicare	supplement	policy	or	certificate	replaces	another	Medicare	supplement	policy	or	certificate,	the	replacing	
    issuer	shall	waive	any	time	periods	applicable	to	preexisting	conditions,	waiting	periods,	elimination	periods	and	
    probationary periods in the new Medicare supplement policy or certificate to the extent such time was spent under the
    original policy.
2. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in
   effect	for	at	least	six	(6)	months,	the	replacing	policy	shall	not	provide	any	time	period	applicable	to	preexisting	conditions,	
   waiting	periods,	elimination	periods	and	probationary	periods.
3.	 If,	you	still	wish	to	terminate	your	present	policy	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*
  United of Omaha Life Insurance Company,	Mutual	of	Omaha	Plaza,	Omaha,	NE		68175
 Applicant                                                            Applicant B
 Signature                                                            Signature

 Date                                                                 Date

*Signature not required for direct response sales.
U7563_GA                                1	-	Home	Office	Copy																		2	-	Applicant	Copy
United of Omaha Life Insurance 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	United	of	Omaha	Life	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 B
        Additional benefits                                                  Additional benefits
        No	change	in	benefits,	but	lower	premiums                            No	change	in	benefits,	but	lower	premiums
        Fewer	benefits	and	lower	premiums                                    Fewer	benefits	and	lower	premiums
        My plan has outpatient prescription drug coverage                    My plan has outpatient prescription drug coverage and I
        and I am enrolling in Part D                                         am enrolling in Part D
        Disenrollment from a Medicare Advantage Plan Please                  Disenrollment from a Medicare Advantage Plan Please
        explain reason for disenrollment                                     explain reason for disenrollment
        Other	(please	specify)___________________________                    Other	(please	specify)_____________________________



1.	 If	a	Medicare	supplement	policy	or	certificate	replaces	another	Medicare	supplement	policy	or	certificate,	the	replacing	
    issuer	shall	waive	any	time	periods	applicable	to	preexisting	conditions,	waiting	periods,	elimination	periods	and	
    probationary periods in the new Medicare supplement policy or certificate to the extent such time was spent under the
    original policy.
2. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in
   effect	for	at	least	six	(6)	months,	the	replacing	policy	shall	not	provide	any	time	period	applicable	to	preexisting	conditions,	
   waiting	periods,	elimination	periods	and	probationary	periods.
3.	 If,	you	still	wish	to	terminate	your	present	policy	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*
  United of Omaha Life Insurance Company,	Mutual	of	Omaha	Plaza,	Omaha,	NE		68175
 Applicant                                                            Applicant B
 Signature                                                            Signature

 Date                                                                 Date

*Signature not required for direct response sales.
U7563_GA                                1	-	Home	Office	Copy																		2	-	Applicant	Copy
United of Omaha Life Insurance Company
A Mutual of Omaha Company



2010 Medicare Supplement Insurance Plans



Plans with coverage effective dates on and after June 1.




Georgia                                                    U8183_GA_0010R
                                            UNITED OF OMAHA LIFE INSURANCE COMPANY
                                                                  A Mutual of Omaha Company
                                        OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE
                                                              BENEFIT PLANS A, F, G, M AND N
These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A.” Some plans may not
be available in your state. See Outlines of Coverage sections for details about ALL plans. Plans E, H, I, and J are no longer available for sale.
Basic Benefits:
Hospitalization:          Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses:         Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N
                          require insureds to pay a portion of Part B coinsurance or copayments.
Blood:                    First 3 pints of blood each year.
Hospice:                  Part A coinsurance.
      A             B               C               D         F     F*         G                  K                  L                M                   N
 Basic,        Basic,         Basic,          Basic,        Basic,        Basic,          Hospitalization Hospitalization       Basic,          Basic, including
 including including          including       including     including     including       and preventive and preventive         including       100% Part B
 100%          100%           100%            100%          100%          100%            care paid at     care paid at         100% Part coinsurance,
 Part B co- Part B co- Part B co-             Part B co-    Part B co- Part B co-         100%; other      100%; other basic B co-              except up to $20
 insurance insurance insurance                insurance     insurance insurance           basic benefits   benefits paid at     insurance copayment for
                                                            *                             paid at 50%      75%                                  office visit, and up
                                                                                                                                                to $50 copayment
                                                                                                                                                for ER
                              Skilled         Skilled       Skilled       Skilled         50% Skilled      75% Skilled          Skilled         Skilled Nursing
                              Nursing         Nursing       Nursing       Nursing         Nursing Facility Nursing Facility     Nursing         Facility
                              Facility Co- Facility Co- Facility          Facility        Coinsurance      Coinsurance          Facility        Coinsurance
                              insurance       insurance     Co-           Co-                                                   Co-
                                                            insurance insurance                                                 insurance
               Part A         Part A          Part A        Part A        Part A          50% Part A       75% Part A           50% Part A Part A Deductible
               Deductible Deductible Deductible Deductible Deductible                     Deductible       Deductible           Deductible
                              Part B                        Part B
                              Deductible                    Deductible
                                                            Part B        Part B
                                                            Excess        Excess
                                                            (100%)        (100%)
                              Foreign         Foreign       Foreign       Foreign                                               Foreign         Foreign Travel
                              Travel          Travel        Travel        Travel                                                Travel          Emergency
                              Emer-           Emer-         Emer-         Emer-                                                 Emer-
                              gency           gency         gency         gency                                                 gency
                                                                                          Out-of-pocket    Out-of-pocket
                                                                                          limit $4,620;    limit $2,310; paid
                                                                                          paid at 100%     at 100% after limit
                                                                                          after limit      reached
                                                                                          reached
*Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,000
deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,000. Out-of-pocket expenses for this deductible are
expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the
plans' separate foreign travel emergency deductible.

CP39                                                                         1                                                          U8183_GA_0010R
                                   UNITED OF OMAHA LIFE INSURANCE COMPANY
                                               MONTHLY NON-TOBACCO RATES*
                                               ZIP CODES: 304-307, 310, 312, 315-319, 398


                        FEMALE                                                                        MALE
 Plan A      Plan F       Plan G      Plan M        Plan N     Issue Age        Plan A     Plan F    Plan G        Plan M         Plan N
 UM20         UM23         UM24        UM30         UM31                        UM20       UM23       UM24          UM30          UM31
  76.48       110.84        94.22      88.12         82.58           65          83.18     120.55     102.47         95.83         89.81
  79.70       115.51        98.18      91.83         86.06           66          87.62     127.00     107.94        100.96         94.61
  82.97       120.24       102.21      95.60         89.58           67          92.13     133.53     113.51        106.16         99.48
  86.22       124.95       106.21      99.34         93.09           68          96.62     140.04     119.03        111.33        104.33
  89.43       129.61       110.17      103.04        96.56           69         101.01     146.38     124.43        116.38        109.05
  92.57       134.15       114.03      106.65        99.94           70         105.20     152.46     129.59        121.21        113.59
  94.97       137.64       117.00      109.42       102.55           71         108.48     157.22     133.64        124.99        117.13
  97.29       141.00       119.85      112.09       105.05           72         111.57     161.69     137.44        128.55        120.46
  99.49       144.18       122.56      114.62       107.41           73         114.41     165.80     140.93        131.82        123.53
 101.55       147.18       125.09      117.00       109.65           74         116.92     169.44     144.03        134.71        126.23
 103.45       149.93       127.44      119.19       111.69           75         119.04     172.51     146.64        137.15        128.52
 105.22       152.50       129.63      121.23       113.61           76         120.72     174.96     148.72        139.09        130.34
 106.95       155.00       131.75      123.22       115.47           77         122.10     176.96     150.41        140.68        131.84
 108.68       157.51       133.88      125.22       117.34           78         123.36     178.78     151.97        142.13        133.19
 110.42       160.02       136.02      127.22       119.22           79         124.45     180.36     153.31        143.39        134.37
 112.14       162.52       138.14      129.21       121.08           80         125.34     181.65     154.40        144.41        135.33
 113.82       164.95       140.21      131.14       122.89           81         126.05     182.67     155.27        145.22        136.09
 115.37       167.20       142.13      132.93       124.56           82         126.66     183.57     156.03        145.93        136.76
 116.79       169.26       143.87      134.57       126.10           83         127.19     184.33     156.68        146.54        137.33
 118.08       171.14       145.47      136.06       127.50           84         127.60     184.93     157.20        147.02        137.78
 119.22       172.79       146.87      137.37       128.73           85         127.93     185.42     157.60        147.41        138.13
 120.21       174.21       148.08      138.50       129.79           86         128.19     185.79     157.92        147.70        138.41
 121.01       175.37       149.06      139.42       130.65           87         128.38     186.05     158.14        147.91        138.61
 121.60       176.23       149.80      140.11       131.29           88         128.49     186.21     158.28        148.04        138.73
 121.99       176.79       150.27      140.55       131.71           89         128.55     186.29     158.36        148.11        138.79
 122.13       177.00       150.45      140.71       131.87          90+         128.56     186.32     158.36        148.12        138.80
                    *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
        To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, and 3, respectively.



RP39.11.B
                                                                  2                                                 U8183_GA_0010R
                                   UNITED OF OMAHA LIFE INSURANCE COMPANY
                                                  MONTHLY TOBACCO RATES*
                                               ZIP CODES: 304-307, 310, 312, 315-319, 398


                        FEMALE                                                                        MALE
 Plan A      Plan F       Plan G      Plan M        Plan N     Issue Age        Plan A     Plan F    Plan G        Plan M         Plan N
 UM20         UM23         UM24        UM30         UM31                        UM20       UM23       UM24          UM30          UM31
  87.91       127.41       108.30      101.29        94.92           65          95.61     138.56     117.78        110.15        103.22
  91.61       132.77       112.85      105.55        98.91           66         100.72     145.97     124.07        116.05        108.75
  95.37       138.21       117.48      109.88       102.97           67         105.90     153.48     130.47        122.02        114.34
  99.10       143.62       122.08      114.18       107.00           68         111.06     160.96     136.82        127.97        119.92
 102.79       148.98       126.63      118.44       110.99           69         116.10     168.26     143.02        133.76        125.35
 106.40       154.20       131.07      122.59       114.88           70         120.92     175.24     148.95        139.32        130.56
 109.17       158.21       134.48      125.77       117.87           71         124.69     180.71     153.60        143.67        134.63
 111.83       162.07       137.76      128.84       120.74           72         128.24     185.85     157.97        147.76        138.46
 114.35       165.72       140.87      131.75       123.46           73         131.50     190.58     161.99        151.51        141.98
 116.72       169.17       143.79      134.49       126.03           74         134.39     194.76     165.55        154.84        145.10
 118.91       172.33       146.48      137.00       128.38           75         136.82     198.29     168.55        157.64        147.72
 120.95       175.29       149.00      139.35       130.59           76         138.76     201.10     170.94        159.88        149.82
 122.93       178.16       151.44      141.64       132.73           77         140.34     203.41     172.89        161.70        151.54
 124.92       181.04       153.88      143.93       134.88           78         141.80     205.50     174.68        163.37        153.09
 126.91       183.93       156.34      146.23       137.03           79         143.05     207.32     176.21        164.82        154.45
 128.89       186.80       158.78      148.51       139.17           80         144.07     208.79     177.47        165.99        155.55
 130.82       189.60       161.16      150.73       141.25           81         144.88     209.97     178.47        166.92        156.43
 132.61       192.19       163.36      152.79       143.17           82         145.59     211.00     179.35        167.74        157.19
 134.24       194.56       165.37      154.67       144.94           83         146.19     211.87     180.09        168.44        157.85
 135.73       196.72       167.20      156.39       146.56           84         146.67     212.57     180.68        168.99        158.36
 137.04       198.61       168.82      157.90       147.97           85         147.05     213.12     181.15        169.43        158.77
 138.17       200.24       170.20      159.20       149.18           86         147.35     213.55     181.52        169.77        159.09
 139.09       201.57       171.33      160.25       150.17           87         147.56     213.85     181.77        170.01        159.32
 139.77       202.56       172.18      161.04       150.91           88         147.69     214.04     181.93        170.16        159.46
 140.22       203.21       172.73      161.55       151.39           89         147.76     214.13     182.02        170.24        159.53
 140.38       203.45       172.93      161.74       151.57          90+         147.76     214.16     182.03        170.26        159.55
                    *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
        To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, and 3, respectively.



RP39.11.B
                                                                  3                                                 U8183_GA_0010R
                                   UNITED OF OMAHA LIFE INSURANCE COMPANY
                                               MONTHLY NON-TOBACCO RATES*
                                             ZIP CODES: 300-303, 308-309, 311, 313-314, 399


                        FEMALE                                                                        MALE
 Plan A      Plan F       Plan G      Plan M        Plan N     Issue Age        Plan A     Plan F    Plan G        Plan M         Plan N
 UM20         UM23         UM24        UM30         UM31                        UM20       UM23       UM24          UM30          UM31
  83.68       121.28       103.09      96.41         90.35           65          91.01     131.89     112.11        104.85         98.26
  87.20       126.38       107.42      100.47        94.16           66          95.87     138.95     118.11        110.47        103.52
  90.78       131.56       111.83      104.59        98.01           67         100.81     146.10     124.19        116.15        108.84
  94.33       136.71       116.20      108.69       101.85           68         105.72     153.22     130.23        121.81        114.15
  97.84       141.81       120.54      112.74       105.65           69         110.52     160.16     136.14        127.33        119.32
 101.28       146.78       124.76      116.69       109.35           70         115.10     166.81     141.79        132.62        124.28
 103.91       150.60       128.01      119.72       112.20           71         118.69     172.02     146.21        136.75        128.15
 106.45       154.27       131.13      122.64       114.93           72         122.07     176.91     150.37        140.65        131.79
 108.85       157.75       134.09      125.41       117.52           73         125.18     181.41     154.20        144.22        135.15
 111.11       161.03       136.87      128.02       119.97           74         127.92     185.39     157.58        147.39        138.11
 113.19       164.04       139.43      130.41       122.21           75         130.24     188.75     160.44        150.06        140.61
 115.13       166.85       141.83      132.64       124.30           76         132.09     191.43     162.72        152.18        142.61
 117.01       169.59       144.15      134.82       126.34           77         133.59     193.62     164.57        153.92        144.25
 118.91       172.33       146.48      137.01       128.39           78         134.97     195.61     166.27        155.51        145.73
 120.81       175.08       148.82      139.19       130.44           79         136.16     197.34     167.73        156.88        147.02
 122.69       177.82       151.14      141.37       132.47           80         137.13     198.75     168.93        158.00        148.07
 124.53       180.48       153.41      143.48       134.46           81         137.91     199.86     169.89        158.89        148.90
 126.23       182.94       155.50      145.44       136.29           82         138.58     200.84     170.72        159.67        149.63
 127.78       185.20       157.41      147.23       137.97           83         139.16     201.68     171.42        160.33        150.25
 129.20       187.25       159.16      148.87       139.51           84         139.61     202.34     171.99        160.86        150.74
 130.44       189.06       160.70      150.30       140.85           85         139.97     202.87     172.44        161.28        151.13
 131.52       190.61       162.01      151.54       142.01           86         140.26     203.27     172.78        161.60        151.44
 132.39       191.87       163.09      152.54       142.94           87         140.46     203.56     173.03        161.83        151.65
 133.05       192.82       163.90      153.29       143.65           88         140.58     203.74     173.18        161.97        151.79
 133.47       193.43       164.42      153.78       144.11           89         140.65     203.83     173.26        162.05        151.85
 133.62       193.66       164.61      153.96       144.28          90+         140.65     203.85     173.27        162.06        151.87
                    *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
        To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, and 3, respectively.



RP39.11.B
                                                                  4                                                 U8183_GA_0010R
                                   UNITED OF OMAHA LIFE INSURANCE COMPANY
                                                  MONTHLY TOBACCO RATES*
                                             ZIP CODES: 300-303, 308-309, 311, 313-314, 399


                        FEMALE                                                                        MALE
 Plan A      Plan F       Plan G      Plan M        Plan N     Issue Age        Plan A     Plan F    Plan G        Plan M         Plan N
 UM20         UM23         UM24        UM30         UM31                        UM20       UM23       UM24          UM30          UM31
  96.18       139.40       118.49      110.82       103.85           65         104.61     151.60     128.86        120.52        112.94
 100.24       145.27       123.48      115.49       108.22           66         110.20     159.71     135.75        126.97        118.98
 104.35       151.22       128.54      120.22       112.66           67         115.87     167.93     142.75        133.50        125.10
 108.43       157.14       133.57      124.93       117.07           68         121.51     176.11     149.69        140.01        131.20
 112.47       163.00       138.55      129.59       121.44           69         127.03     184.09     156.48        146.35        137.15
 116.42       168.71       143.41      134.13       125.69           70         132.30     191.74     162.97        152.44        142.85
 119.44       173.10       147.14      137.61       128.96           71         136.42     197.72     168.06        157.19        147.30
 122.35       177.32       150.73      140.97       132.11           72         140.31     203.34     172.84        161.66        151.49
 125.11       181.32       154.13      144.15       135.08           73         143.88     208.52     177.24        165.77        155.35
 127.71       185.09       157.32      147.15       137.89           74         147.03     213.09     181.13        169.41        158.75
 130.10       188.55       160.27      149.90       140.47           75         149.70     216.95     184.41        172.48        161.63
 132.33       191.79       163.02      152.46       142.88           76         151.82     220.03     187.03        174.92        163.92
 134.50       194.93       165.69      154.97       145.22           77         153.55     222.55     189.16        176.92        165.80
 136.67       198.08       168.37      157.48       147.57           78         155.14     224.84     191.12        178.75        167.50
 138.86       201.24       171.06      159.99       149.93           79         156.51     226.83     192.80        180.33        168.99
 141.03       204.39       173.72      162.49       152.27           80         157.63     228.45     194.18        181.61        170.19
 143.14       207.45       176.33      164.92       154.55           81         158.52     229.73     195.27        182.63        171.15
 145.09       210.27       178.74      167.17       156.65           82         159.29     230.85     196.23        183.53        171.99
 146.88       212.87       180.93      169.23       158.58           83         159.95     231.81     197.04        184.29        172.70
 148.50       215.23       182.94      171.11       160.35           84         160.47     232.57     197.69        184.89        173.27
 149.94       217.30       184.71      172.76       161.89           85         160.89     233.18     198.20        185.38        173.72
 151.17       219.09       186.22      174.18       163.22           86         161.22     233.64     198.60        185.75        174.07
 152.18       220.54       187.46      175.33       164.30           87         161.45     233.98     198.88        186.01        174.31
 152.93       221.63       188.39      176.20       165.11           88         161.59     234.18     199.06        186.18        174.47
 153.41       222.34       188.99      176.76       165.64           89         161.66     234.29     199.15        186.26        174.54
 153.59       222.60       189.21      176.96       165.84          90+         161.67     234.31     199.16        186.28        174.56
                    *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
        To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, and 3, respectively.



RP39.11.B
                                                                  5                                                 U8183_GA_0010R
Disclosures                                                 policyholder chooses to terminate their Medicare Supplement
Use this outline to compare benefits and premiums           policy or he or she no longer resides with you (other than in
among policies.                                             the case of their death).

This outline shows benefits and premiums of policies        Read Your Policy Very Carefully
sold for effective dates on or after June 1, 2010.          This is only an outline describing your policy's most important
Policies sold for effective dates prior to June 1, 2010     features. The policy is your insurance contract. You must
have different benefits and premiums. Plans E, H, I,        read the policy itself to understand all of the rights and duties
and J are no longer available for sale.                     of both you and your insurance company.

Premium Information                                         Right to Return Policy
We, United of Omaha, can only raise your premium if         If you find that you are not satisfied with your policy, you may
we raise the premium for all the policies like yours in     return it to United of Omaha Life Insurance Company, Mutual
the same geographic area of the state where you live.       of Omaha Plaza, Omaha, NE 68175. If you send the policy
                                                            back to us within 30 days after you receive it, we will treat the
Risk Class Rating                                           policy as if it had never been issued and return all of your
If, according to our underwriting standards, you are        payments.
overweight or underweight for your height, you will be
considered to be a greater insurable risk. In such a        Policy Replacement
case, your premium will be priced either as Class I -       If you are replacing another health insurance policy, do NOT
10% or Class II - 20% higher than the rates illustrated,    cancel it until you have actually received your new policy and
based on your Body Mass Index (BMI) reading. Risk           are sure you want to keep it.
class rating will not be applicable when you apply for
coverage during an open enrollment or guaranteed            Notice
issue period.                                               The policy may not fully cover all of your medical costs.
                                                            Neither United of Omaha nor its agents are connected with
Household Premium Discount                                  Medicare. This outline of coverage does not give all the
If you resided with at least one, but no more than three,   details of Medicare coverage. Contact your local Social
other Medicare eligible adults for the past year, or you    Security office or consult "Medicare & You" for more details.
are married, and at least one of these other adults or
your spouse also owns or is issued a Medicare               Complete Answers Are Very Important
Supplement policy underwritten by United of Omaha or        When you fill out the application for the new policy, be sure
its affiliates, you will be eligible for a household        to answer truthfully and completely all questions about your
premium discount. The discounted premium will be            medical and health history. The Company may cancel your
priced 7% lower than the rates illustrated. Your            policy and refuse to pay any claims if you leave out or falsify
policy's household premium discount will be removed if      important medical information. Review the application
your spouse or the other Medicare Supplement                carefully before you sign it. Be certain that all information
                                                            has been properly recorded.



DP2B                                                        6                                                  U8183_GA_0010R
                                                                           PLAN A
                                   MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the
hospital and have not received skilled care in any other facility for 60 days in a row.
                                       Services                                      Medicare Pays           Plan A Pays          You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing and miscellaneous services and
 supplies
          First 60 days                                                         All but $1,100        $0                 $1,100 (Part A
                                                                                                                         Deductible)
             st           th
          61 through 90 day                                                     All but $275 a day    $275 a day         $0
          91st day and after:
              While using 60 lifetime reserve days                              All but $550 a day    $550 a day         $0
          Once lifetime reserve days are used:
              Additional 365 days                                               $0                    100% of Medicare   $0**
                                                                                                      Eligible Expenses
              Beyond the additional 365 days                                    $0                    $0                 All costs
 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements, including having been in a hospital for
 at least 3 days and entered a Medicare approved facility within 30 days after
 leaving the hospital.
          First 20 days
                                                                                All approved amounts  $0                 $0
          21st through 100th day                                                All but $137.50 a day $0                 Up to $137.50 a day
        101st day and after                                                        $0            $0                      All costs
BLOOD
        First 3 pints                                               $0                       3 pints                 $0
        Additional amounts                                          100%                     $0                      $0
HOSPICE CARE                                                        All but very limited     Medicare copayment/     $0
                                                                    copayment/coinsurance coinsurance
You must meet Medicare's requirements, including a doctor's certification of
terminal illness.                                                   for outpatient drugs and
                                                                    inpatient respite care
**NOTICE: When your Medicare Part A hospital benefits are                     During this time the hospital is prohibited from billing you
exhausted, the insurer stands in the place of Medicare and will pay           for the balance based on any difference between its
whatever amount Medicare would have paid for up to an additional              billed charges and the amount Medicare would have
365 days as provided in the policy/certificate's "Core Benefits."             paid.


BC39                                                                           7                                       U8183_GA_0010R
                                                                       PLAN A
                                   MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $155 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B
Deductible will have been met for the calendar year.

                                    Services                                       Medicare Pays         Plan A Pays            You Pay
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT
HOSPITAL TREATMENT, such as physician’s services, inpatient and
outpatient medical and surgical services and supplies, physical and speech
therapy, diagnostic tests, durable medical equipment
        First $155 of Medicare Approved Amounts*
                                                                             $0                    $0                   $155 (Part B Deductible)
        Remainder of Medicare Approved Amounts                               Generally 80%         Generally 20%        $0
Part B Excess Charges (above Medicare Approved Amounts)                      $0                    $0                   All costs
BLOOD
        First 3 pints                                                        $0                    All costs            $0
        Next $155 of Medicare Approved Amounts*                              $0                    $0                   $155 (Part B Deductible)
      Remainder of Medicare Approved Amounts                                 80%                   20%                  $0
CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC
SERVICES                                                                     100%                  $0                   $0

                                                                  PARTS A AND B

HOME HEALTH CARE—MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies               100%                  $0                   $0
Durable medical equipment
        First $155 of Medicare Approved Amounts*                             $0                    $0                   $155 (Part B Deductible)
        Remainder of Medicare Approved Amounts                               80%                   20%                  $0




BC39                                                                    8                                              U8183_GA_0010R
                                                                 PLANS F AND G
                                         MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the
hospital and have not received skilled care in any other facility for 60 days in a row.
                        Services                         Medicare Pays          Plan F Pays             You Pay        Plan G Pays            You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
           First 60 days                             All but $1,100        $1,100 (Part A         $0               $1,100 (Part A      $0
                                                                           Deductible)                             Deductible)
           61st through 90th day                     All but $275 a day    $275 a day             $0               $275 a day          $0
              st
           91 day and after:
               While using 60 lifetime reserve       All but $550 a day    $550 a day             $0               $550 a day          $0
 days
           Once lifetime reserve days are used:
               Additional 365 days                   $0                    100% of Medicare       $0**             100% of Medicare    $0**
                                                                           Eligible Expenses                       Eligible Expenses
               Beyond the additional 365 days        $0                    $0                     All costs        $0                  All costs
 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital for at least
 3 days and entered a Medicare approved
 facility within 30 days after leaving the hospital.
           First 20 days
                                                     All approved amounts $0                      $0               $0                  $0
              st through 100th day
           21                                        All but $137.50 a day Up to $137.50 a day $0                  Up to $137.50 a day $0
           101st day and after                       $0                    $0                     All costs        $0                  All costs
 BLOOD
           First 3 pints                             $0                    3 pints                $0               3 pints             $0
           Additional amounts                        100%                  $0                     $0               $0                  $0
 HOSPICE CARE                                        All but very limited  Medicare               $0               Medicare            $0
 You must meet Medicare's requirements,              copayment/coinsuran copayment/coinsuran                       copayment/coinsura
 including a doctor's certification of terminal      ce for outpatient     ce                                      nce
 illness.                                            drugs and inpatient
                                                     respite care
**NOTICE: When your Medicare Part A hospital benefits are                                    During this time the hospital is prohibited from billing you
exhausted, the insurer stands in the place of Medicare and will pay                          for the balance based on any difference between its
whatever amount Medicare would have paid for up to an additional                             billed charges and the amount Medicare would have
365 days as provided in the policy/certificate's "Core Benefits."                            paid.

BC39                                                                    9                                                      U8183_GA_0010R
                                                                 PLANS F AND G
                                   MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $155 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B
Deductible will have been met for the calendar year.
                                Services                              Medicare Pays   Plan F Pays    You Pay   Plan G Pays    You Pay
 MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND
 OUTPATIENT HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical and surgical services and
 supplies, physical and speech therapy, diagnostic tests, durable
 medical equipment
         First $155 of Medicare Approved Amounts*                     $0            $155 (Part B  $0         $0            $155 (Part B
                                                                                    Deductible)                            Deductible)
         Remainder of Medicare Approved Amounts                       Generally 80% Generally 20% $0         Generally 20% $0
 Part B Excess Charges (above Medicare Approved Amounts)              $0            100%          $0         100%          $0
BLOOD
        First 3 pints                                            $0         All costs      $0             All costs       $0
        Next $155 of Medicare Approved Amounts*                  $0         $155 (Part B   $0             $0              $155 (Part B
                                                                            Deductible)                                   Deductible)
      Remainder of Medicare Approved Amounts                     80%        20%            $0             20%             $0
CLINICAL LABORATORY SERVICES—TESTS FOR
DIAGNOSTIC SERVICES                                              100%       $0             $0             $0              $0

                                                                 PARTS A AND B

HOME HEALTH CARE—MEDICARE APPROVED SERVICES
Medically necessary skilled care services and medical supplies   100%       $0             $0             $0              $0
Durable medical equipment
        First $155 of Medicare Approved Amounts*                 $0         $155 (Part B   $0             $0              $155 (Part B
                                                                            Deductible)                                   Deductible)
        Remainder of Medicare Approved Amounts                   80%        20%            $0             20%             $0




BC39                                                                   10                                       U8183_GA_0010R
                                                            PLANS F AND G
                               MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

                                                 OTHER BENEFITS – NOT COVERED BY MEDICARE
                       Services                         Medicare Pays Plan F Pays             You Pay        Plan G Pays           You Pay
FOREIGN TRAVEL—NOT COVERED BY MEDICARE
Medically necessary emergency care services
beginning during the first 60 days of each trip outside
the USA
        First $250 each calendar year                   $0            $0                $250               $0                   $250
        Remainder of charges                            $0            80% to a lifetime 20% and amounts    80% to a lifetime    20% and amounts
                                                                      Maximum Benefit over the $50,000     Maximum Benefit of   over the $50,000
                                                                      of $50,000        lifetime Maximum   $50,000              lifetime Maximum
                                                                                        Benefit                                 Benefit




BC39                                                              11                                                   U8183_GA_0010R
                                                                     PLANS M AND N
                                         MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the
hospital and have not received skilled care in any other facility for 60 days in a row.
                        Services                         Medicare Pays           Plan M Pays             You Pay              Plan N Pays                You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
           First 60 days                             All but $1,100         $550 (50% of Part A $550 (50% of Part $1,100 (Part A                 $0
                                                                            Deductible)            A deductible)        Deductible)
           61st through 90th day                     All but $275 a day     $275 a day             $0                   $275 a day               $0
              st
           91 day and after:
              While using 60 lifetime reserve days All but $550 a day       $550 a day             $0                   $550 a day               $0
           Once lifetime reserve days are used:
               Additional 365 days                   $0                     100% of Medicare       $0**                 100% of Medicare         $0**
                                                                            Eligible Expenses                           Eligible Expenses
               Beyond the additional 365 days        $0                     $0                     All costs            $0                       All costs
 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital for at least
 3 days and entered a Medicare approved
 facility within 30 days after leaving the hospital.
           First 20 days
                                                     All approved amounts $0                       $0                   $0                       $0
           21st through 100th day                    All but $137.50 a day Up to $137.50 a day $0                       Up to $137.50 a day $0
           101st day and after                       $0                     $0                     All costs            $0                       All costs
 BLOOD
           First 3 pints                             $0                     3 pints                $0                   3 pints                  $0
           Additional amounts                        100%                   $0                     $0                   $0                       $0
 HOSPICE CARE                                        All but very limited   Medicare copayment $0                       Medicare                 $0
 You must meet Medicare's requirements,              copayment/             /coinsurance                                copayment/
 including a doctor's certification of terminal      coinsurance for                                                    coinsurance
 illness.                                            outpatient drugs and
                                                     inpatient respite care
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the                      During this time the hospital is prohibited from billing you for the
insurer stands in the place of Medicare and will pay whatever amount Medicare                 balance based on any difference between its billed charges and the
would have paid for up to an additional 365 days as provided in the                           amount Medicare would have paid.
policy/certificate's "Core Benefits."


BC39                                                                        12                                                          U8183_GA_0010R
                                                                 PLANS M AND N
                                  MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $155 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B
Deductible will have been met for the calendar year.
                                Services                              Medicare Pays Plan M Pays    You Pay       Plan N Pays              You Pay
 MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND
 OUTPATIENT HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical and surgical services and
 supplies, physical and speech therapy, diagnostic tests, durable
 medical equipment
         First $155 of Medicare Approved Amounts*                     $0            $0          $155 (Part B $0                   $155 (Part B
                                                                                                Deductible)                       Deductible)
         Remainder of Medicare Approved Amounts                       Generally 80% Generally   $0           Balance, other than Up to $20 per office
                                                                                    20%                      up to $20 per office visit and up to $50 per
                                                                                                             visit and up to $50 emergency room visit.
                                                                                                             per emergency        The copayment of up
                                                                                                             room visit. The      to $50 is waived if the
                                                                                                             copayment of up to insured is admitted to
                                                                                                             $50 is waived if the any hospital and the
                                                                                                             insured is admitted emergency visit is
                                                                                                             to any hospital and covered as a
                                                                                                             the emergency visit Medicare Part A
                                                                                                             is covered as a      expense.
                                                                                                             Medicare Part A
                                                                                                             expense.
 Part B Excess Charges (above Medicare Approved Amounts)              $0            $0          All costs    $0                   All costs
 BLOOD
         First 3 pints                                                $0            All costs   $0           All costs            $0
         Next $155 of Medicare Approved Amounts*                      $0            $0          $155 (Part B $0                   $155 (Part B
                                                                                                Deductible)                       Deductible)
         Remainder of Medicare Approved Amounts                       80%           20%         $0           20%                  $0
 CLINICAL LABORATORY SERVICES—TESTS FOR
 DIAGNOSTIC SERVICES                                                  100%          $0          $0           $0                   $0




BC39                                                                   13                                                     U8183_GA_0010R
                                                              PLANS M AND N
                                   MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

                                                               PARTS A AND B

                        Services                             Medicare       Plan M               You Pay             Plan N Pays          You Pay
                                                              Pays           Pays
HOME HEALTH CARE—MEDICARE APPROVED
SERVICES                                                100%              $0                $0                  $0                   $0
Medically necessary skilled care services and medical
supplies
Durable medical equipment
        First $155 of Medicare Approved Amounts*        $0                $0                $155 (Part B        $0                   $155 (Part B
                                                                                            Deductible)                              Deductible)
        Remainder of Medicare Approved Amounts          80%               20%               $0                  20%                  $0


                                              OTHER BENEFITS – NOT COVERED BY MEDICARE

FOREIGN TRAVEL—NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning
during the first 60 days of each trip outside the USA
         First $250 each calendar year
                                                        $0              $0                   $250               $0                   $250
        Remainder of charges                            $0              80% to a lifetime    20% and amounts    80% to a lifetime    20% and amounts
                                                                        Maximum              over the $50,000   Maximum Benefit of   over the $50,000
                                                                        Benefit of           lifetime Maximum   $50,000              lifetime Maximum
                                                                        $50,000              Benefit                                 Benefit




BC39                                                               14                                                       U8183_GA_0010R

				
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