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Proof of Death Form

Group Operation

Please Return Completed Form To:

United of Omaha Life Insurance Company

Group Life Claims

Mutual of Omaha Plaza

Omaha, NE 68175-0001

Toll Free 1-800-775-8805

Instructions for Furnishing Proof of Death

1. Beneficiary or other claimant should complete Part II. Attach certified copy of deceased’s Death Certificate and return to

Policyholder or Group Administrator for completion of Part I.

2. If any beneficiary, other than a contingent beneficiary, died before the Insured, a copy of the Certificate of Death of such

beneficiary must be attached to the proofs. In such case, claim should be made by the other beneficiaries, or if there be

none, by the duly appointed representative of the Insured’s estate.

3. If claim is made on behalf of the estate of the deceased, a certified copy of the Letters of Administration must be attached

to the proofs.

4. If any beneficiary is a minor or legally incompetent, a certified copy of the appointment of a guardian must be attached to

the proofs.

5. IMPORTANT: Attach original enrollment record plus any beneficiary changes.

Authorization To Disclose Personal Information

To physicians, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers, other medical care

facilities, health maintenance organizations, insurers, employers, consumer reporting agencies and all other providers of

medical or dental services.

I authorize you to release to representatives of United of Omaha Life Insurance Company, personal information about the

insued person including: medical history, mental and physical condition, prescription drug records, alcohol or drug use,

financial and occupational information in order to evaluate my claim for benefits.

If the person or entity to whom information is disclosed is not a health care provider or health plan subject to federal privacy

regulations, the information may be redisclosed without the protection of the federal privacy regulations.

I understand that I may refuse to sign this authorization. I realize that if I refuse to sign, my claim for benefits may not be paid.

This authorization will expire 24 months after the date signed. I may revoke this authorization at any time by written notice to;

ATTN: Group Life Claims, United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175-0001. Any

revocation of this authorization will not affect any use or disclosure of Personal Information that occurred prior to the receipt of

my revocation.

I understand that I am entitled to receive a copy of the authorization and that a copy is as valid as the original.

Name(s) used for medical records (if different than the name below): _________________________________________________

___________________________________________________________________________________________________________

______________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________

Printed Name of Insured Person

Printed Name of Authorized Person

Signature of Authorized Person

______________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Relationship to Insured

Date

LG2836_0403

Group Claim Fraud Statements - United Of Omaha Life Insurance Company/proof Of Death Form Page 3

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