Policies underwritten by United of Omaha Life Insurance Company (United of Omaha)

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State:  
Child's Name Gender Date of Birth

First:                     Mi:      Last:                           Suffix:
Male Female

First:                     Mi:      Last:                           Suffix:
Male Female

Exclusions: No benefits are paid for death resulting from suicide while sane or insane within two years from the policy issue date (one year in Colorado, Missouri and North Dakota). Instead, the total of all premiums paid will be returned to the beneficiary. And all benefits will be paid minus any outstanding policy loans.

 
AFN39594-2_0807
 

United of Omaha Life Insurance Company
Mutual of Omaha Plaza, Omaha NE 68175
Policy form A006LNA05P or state equivalent (A132LOK05P in OK, A150LTX05P in TX)
© 2007 United of Omaha Life Insurance Company. All Rights Reserved
Each underwriting company is solely responsible for its contractual obligations.
United of Omaha Life Insurance Company is licensed nationwide, except in New York.