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Part I Statement of Policyholder or Group Administrator

Employee

Spouse

Child

Other

Eff. date of

Full name

deceased

of deceased _______________________________________ Soc. Sec. No. _____________________ insurance __________

Eff. date of

Name of

employee’s

Employee _________________________________________ Soc. Sec. No. _____________________ insurance __________

Date employment began ____________________________ Occupation at time of death______________________________

Date of last active work _____________________________ If retired, date retired ___________________________________

Premium for the above deceased has been paid through _______________________________________________________

If date deceased last worked was more than 31 days prior to death, was deceased:

totally disabled?

on leave of absence?

on temporary layoff?

If benefits are based on earnings, give amount of monthly earnings ______________________________________________

(Note: We may require supporting documentation of earnings and paid premiums to process the claim.)

If your plan has more than one class, show class deceased was covered under ____________________________________

Name of beneficiary shown on your records____________________________ Relationship ___________________________

Note: Attach Original Enrollment Record plus any beneficiary changes.

We hereby certify that to the best of our knowledge and belief, the above statements are correct and that said deceased’s

insurance was in force on the date of his or her death for the amount of $_________________.

Master Policy No. _________________________________

_________________________________________________

Name of Policyholder

Date ____________________________________________

By _______________________________________________

Signature and Title

Part II Statement of Beneficiary or Other Claimant

Full name of deceased ____________________________________________________________________________________

Date of birth of deceased __________________________________ Your date of birth _______________________________

(

)

Your relationship to the insured ____________________________Your telephone no. ________________________________

Your address ____________________________________________________________________________________________

Street

City or Town

State

ZIP Code

If you are not the named beneficiary, in what capacity do you make this claim? ____________________________________

_______________________________________________________________________________________________________

Your (Claimant’s) Taxpayer Identification Number

For exempt payees write “Exempt” here _____________________________________________________________________

Social Security Number ______ - ______ - ______

Employer Identification Number _____ - _____

CERTIFICATION — Under penalty of perjury, I certify that:

(a)

The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a

number to be issued to me); and

(b)

I am not subject to backup withholding either because I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of failure to report all interest and

dividends, or the IRS has notified me that I am no longer subject to backup withholding.

Does the deceased have any other life insurance coverage with Mutual of Omaha? Yes ____ No ____

_________________________________________

____/____/____

______________________________________________

Signature of Claimant

Date

Relationship To Insured

Mailing Address of Claimant

_____________________________________________________

________________________________________________

Street

City

State

ZIP Code

Please Complete Authorization on Reverse Side

Group Claim Fraud Statements - United Of Omaha Life Insurance Company/proof Of Death Form Page 4

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