Group Benefit Services Application For Accidental Death Benefits - Mutual Of Omaha Insurance Company Page 3

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Group Benefit Services Application for

Accidental Death Benefits

Please Return Completed Form To:

Mutual of Omaha Insurance Company

Group Life Claims

Mutual of Omaha Plaza

Omaha, NE 68175

Toll Free 1-800-775-8805

Certified Copy of Death Certificate Must be Furnished With This Proof.

Statement of Beneficiary or Other Claimant

1. Your full name ____________________________________________________________________ Date of Birth ____________

2. Your relationship to deceased _______________________________________________________________________________

3. Full name of deceased ________________________________________________ Deceased’s date of birth ______________

4. Last legal address of deceased ______________________________________________________________________________

Street

City or Town

State

5. State date of accident upon which claim is based ______________________________________________________________

6. How did the injury occur? ___________________________________________________________________________________

7. Your telephone number ____________________________________________________________________________________

8. What injury or injuries were received? _________________________________________________________________________

9. Who was present when the deceased was injured? (Give full names and addresses) __________________________________

_________________________________________________________________________________________________________

10. Was an inquest held? ________________________

11. Was an autopsy held?________________________________

12. State name and address of doctor first called after this injury. Also, name of doctor who attended deceased at time of death ____

_________________________________________________________________________________________________________

13. Was deceased sick from any cause within five years preceding death? _____________________________________________

If so, state name of disease and name and address of the physician who attended him or her in such sickness ___________

_________________________________________________________________________________________________________

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

Please attach a copy of the police report and toxicology records.

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 Mutual of Omaha Insurance Company, personal information about the insured

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, Mutual of Omaha 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

MUG6774_0812Statement of Attending Physician