SC3Q_P230410616002000022

325 RAINTREE DR APT 29

TX 75703
RONALD L SANDERS
TYLER

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 .

RONALD L SANDERS
50AD4-547600-96M

YOUR POLICY/CERTIFICATE IS ENCLOSED

Dear RONALD L SANDERS,

I want to take a moment and thank you for placing your trust in Mutual of Omaha. I know the plan you purchased
will provide you with the important insurance coverage you need.

By choosing Mutual of Omaha, you have placed your confidence and trust in our company. You can have peace of
mind knowing a strong Company with over a Century of experience is here to protect you. We take this
responsibility very seriously -- and will strive to be a valued partner for you and your family.

Your coverage begins on the date shown on your policy and is fully portable individual coverage. Please keep your
policy in a safe place with your other important documents.

Our associates are here to serve you and your needs. If you have any questions regarding your plan, please call
your representative or our Customer Service Department.

Customer Service: 1-800-775-6000

For information regarding claims submission, a pending claim or policy benefit, please contact our Claims
Department.

Claims Department: 1-800-775-1000

Or, if you prefer to write, please address all correspondence to :

MUTUAL OF OMAHA

3300 MUTUAL OF OMAHA PLAZA

OMAHA NE 68175

Again, thank you for selecting Mutual of Omaha for your protection. We look forward to meeting your insurance
needs now -- and in the future.

Sincerely,

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 MUTUAL OF OMAHA
PRIVACY NOTICE - PERSONAL INFORMATION
This is the Privacy Notice of Mutual of Omaha
Insurance Company and certain of its affiliates listed
as follows (collectively, "Mutual of Omaha", "us", "our",
or "we"):
- Companion Life Insurance Company
- Medicare Advantage Insurance Company of
Omaha
- Mutual of Omaha Investor Services, Inc.
- Mutual of Omaha Marketing Corporation
- Mutual of Omaha Medicare Advantage
Company
- Mutual of Omaha Structured Settlement
Company
- Omaha Health Insurance Company
- Omaha Insurance Company
- Omaha Supplemental Insurance Company
- United of Omaha Life Insurance Company
- United World Life Insurance Company
This Notice applies to our current as well as former
customers.
Why You Are Receiving This Notice
This Notice describes the Personal Information
we collect, and how we use and protect it.
Personal Information means information such as
name, address, Social Security number, income,
employment and similar information.
If you have a policy that is covered by the HIPAA
Privacy regulations, you received a privacy notice
that relates to the privacy of your protected health
information. To obtain an additional copy of the
privacy notice related to your protected health
information you can go to our website:
https://www.mutualofomaha.com/legal-services/
privacy-notices-and-forms
(Continued on reverse side)
or you can contact us at:
Mutual of Omaha
Attn: Privacy Office
3300 Mutual of Omaha Plaza
Omaha, NE 68175-1029
Information We Collect
We may collect Personal Information about you
from:
- Applications or other forms we receive from you
- Your transactions with us, such as your
payment history
- Your transactions with other companies
- Other sources (such as motor vehicle reports,
government agencies and medical information
bureaus)
- Consumer-reporting agencies
How We Protect Your Information
We restrict access to your Personal Information.
It is given only to employees of Mutual of Omaha
companies and others who need to know the
information to provide our insurance or financial
services to you. We maintain physical, technical
and administrative safeguards to protect your
Personal Information in compliance with federal
and state law.
Sharing Within Mutual of Omaha
Your Personal Information
We may share your Personal Information among
Mutual of Omaha and with our banking and other
affiliates. We may also share information about
your transactions, such as your payment history.
We do not share your medical information, except
to the extent required or permitted under federal
and state law.
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Your Creditworthiness Information
We may also share certain information about
your creditworthiness among Mutual of
Omaha and with our banking and other
affiliates. It also lets us better match our
products and services with your needs.
Creditworthiness includes:
- Your marital status
- Your income
- Your employment history
- Your credit history
Sharing With Third Parties
We may share your Personal Information with
third parties outside Mutual of Omaha. For
example:
- With our agents and brokers
- To respond to a judicial process or
government regulatory authority
- To process an insurance transaction that
you request
- To service your policy or account, such as
paying a claim
- To allow third parties to perform insurance
or other functions on our behalf
- To other financial institutions with whom we
have joint marketing agreements
We do not share your medical information,
except to the extent required or permitted
under federal and state law.
50AD4-547600-96M
Important Privacy Choices
You may tell us:
1. To not share your Personal Information with
third parties outside the Mutual of Omaha
companies except as required or permitted by
law, and
2. To not share information about your
creditworthiness among Mutual of Omaha or
with our banking or other affiliates.
Just call us toll free at:
1-800-522-6912
When you call, please be prepared to provide
your policy or account number.
Your request will apply to all the products you
have with Mutual of Omaha. If there is more
than one owner of any insurance product or
service, any one of you may request that we not
share Personal Information as described in this
Privacy Notice on behalf of yourself and the
other owners.
We will honor your request for as long as you
are our customer and for as long as we keep
information about you.
If you have already told us to not share your
information, it is not necessary to tell us again
each time you receive a Privacy Notice. Your
request will remain on file with us until you ask
for a change.
 MUTUAL OF OMAHA

AFFILIATE MARKETING OPT-OUT NOTICE

This is the Notice of Mutual of Omaha Insurance other Mutual of Omaha companies. This
Company and certain of its affiliates listed as information may include your income, your
follows (collectively, "Mutual of Omaha", "us", account history, and your credit history.
"our", or "we"):
Your choice to limit marketing offers from the
- Companion Life Insurance Company Mutual of Omaha companies will apply to all
- Medicare Advantage Insurance Company of offers we make after October 1, 2008 until you
Omaha tell us to change your choice.
- Mutual of Omaha Investor Services, Inc.
If there is more than one owner of any insurance
- Mutual of Omaha Marketing Corporation
product or service, any one owner may request
- Mutual of Omaha Medicare Advantage
that we not share information on behalf of the
Company
one owner and the other owners.
- Mutual of Omaha Structured Settlement
Company Your choice to limit marketing offers from the
- Omaha Health Insurance Company Mutual of Omaha companies will apply for at
- Omaha Insurance Company least 5 years from when you tell us your choice.
- Omaha Supplemental Insurance Company Once that period expires, you will receive a
- United of Omaha Life Insurance Company renewal notice that will allow you to continue to
- United World Life Insurance Company limit marketing offers from the Mutual of Omaha
companies for at least another 5 years.
Why You Are Receiving This Notice
If you have already made a choice to limit
Federal law gives you the right to limit some but
marketing offers from the Mutual of Omaha
not all marketing from the Mutual of Omaha
companies, you do not need to act again until
companies. Federal law also requires us to give
you receive the renewal notice.
you this notice to tell you about your choice to limit
marketing from the Mutual of Omaha companies. To limit marketing offers, just check the box

on the Affiliate Marketing Choice Form,

Your Choice to Limit Marketing
complete it and return it to:
You may limit Mutual of Omaha affiliated
Mutual of Omaha
companies, such as our banking affiliate or the
Attn: Privacy Office
Mutual of Omaha companies listed above, from
3300 Mutual of Omaha Plaza
marketing their products or services to you based
Omaha, NE 68175-1029
on personal information that they receive from
456656_0619

$ Detach here - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MUTUAL OF OMAHA

Affiliate Marketing Choice Form

Do not permit your affiliated companies to use my personal information to market their products and
services to me.
Print your name and address clearly

________________________________________________________________________________________________
First Name Middle Initial Last Name

________________________________________________________________________________________________
Address (line 1)

________________________________________________________________________________________________
Address (line 2)

___________________________________________________________________________________________________________
City State and Zip Code

50AD4-547600-96M 456656_0619

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 RONALD L SANDERS
50AD4-547600-96M

How you're protected if your life or health insurance company fails

The Texas Life and Health Insurance Guaranty Association protects you by paying your covered claims if your life or health
insurance company is insolvent (can 't pay its debts). This notice summarizes your protections.

The Association will pay your claims, with some exceptions required by law, if your company is licensed in Texas and a
court has declared it insolvent. You must live in Texas when your company fails. If you don't live in Texas, you may still
have some protections.

For each insolvent company, the Association will pay a person's claims only up to these dollar
limits set by law:

Accident, accident and health, or health insurance (including HMOs):

Up to $500,000 for health benefit plans, with some exceptions.

Up to $300,000 for disability income benefits.
Up to $300,000 for long-term care insurance benefits.
Up to $200,000 for all other types of health insurance.

Life insurance

Up to $100,000 in net cash surrender or withdrawal value.

Up to $300,000 in death benefits.

Individual Annuities: Up to $250,000 in the present value of benefits, including cash surrender and net
cash withdrawal values.

Other policy types: Limits for group policies, retirement plans and structured settlement annuities are in
Chapter 463 of the Texas Insurance Code.

Individual aggregate limit: Up to $300,000 per person, regardless of the number of policies or contracts.
A limit of $500,000 may apply for people with health benefit plans.

Parts of some policies might not be protected: For example, there is no protection for parts of a policy
or contract that the insurance company doesn't guarantee, such as some additions to the value of variable
life or annuity policies.

To learn more about the Association and your protections, For questions about insurance, contact:
contact:

Texas Life and Health Insurance Guaranty Association Texas Department of Insurance

515 Congress Avenue, Suite 1875 P.O. Box 149104

Austin, TX 78701 Austin, TX 78714-9104
1-800-982-6362 or www.txlifega.org 1-800-252-3439 or www.tdi.texas.gov

Note: You're receiving this notice because Texas law requires your insurance company to send you a summary of your
protections under the Texas Life and Health Insurance Guaranty Association Act (Insurance Code, Chapter 463). These
protections apply to insolvencies that occur on or after September 2, 2019. There may be other exceptions that aren' t
included in this notice. When choosing an insurance company, you should not rely on the Association's coverage. Texas

law prohibits companies and agents from using the Association as an inducement to buy insurance or HMO coverage.

Chapter 463 controls if there are differences between the law and this summary.

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Have a complaint or need help?
If you have a problem with a claim or your
premium, call your insurance company or HMO
first. If you can't work out the issue, the Texas
Department of Insurance may be able to help.
Even if you file a complaint with the Texas
Department of Insurance, you should also file a
complaint or appeal through your insurance
company or HMO. If you don't, you may lose
your right to appeal.
Mutual of Omaha Insurance Company
To get information or file a complaint with your
insurance company:
Call Customer Service: 1-800-775-6000
Call Claims: 1-800-775-1000
Mail:
MUTUAL OF OMAHA
3300 MUTUAL OF OMAHA PLAZA
OMAHA NE 68175
The Texas Department of Insurance
To get help with an insurance question or file a
complaint with the state:
Call with a question: 1-800-252-3439
File a complaint: www.tdi.texas.gov
Email: ConsumerProtection@tdi.texas.gov
Mail: MC 111-1A, P.O. Box 149091, Austin, TX
78714-9091
M18645-A REV 2
RONALD L SANDERS
50AD4-547600-96M
¿Tiene una queja o necesita ayuda?
Si tiene un problema con una reclamación o con
su prima de seguro, llame primero a su compañía
de seguros o HMO. Si no puede resolver el
problema, es posible que el Departamento de
Seguros de Texas (Texas Department of
Insurance, por su nombre en inglés) pueda ayudar.
Aun si usted presenta una queja ante el
Departamento de Seguros de Texas, también debe
presentar una queja a través del proceso de quejas
o de apelaciones de su compañía de seguros o
HMO. Si no lo hace, podría perder su derecho
para apelar.
Mutual of Omaha Insurance Company
Para obtener información o para presentar una
queja ante su compañía de seguros o HMO:
Centro de Servicio al Cliente: 1-800-775-6000
Reclamos: 1-800-775-1000
Dirección postal:
MUTUAL OF OMAHA
3300 MUTUAL OF OMAHA PLAZA
OMAHA NE 68175
El Departamento de Seguros de Texas
Para obtener ayuda con una pregunta relacionada
con los seguros o para presentar una queja ante el
estado:
Llame con sus preguntas al: 1-800-252-3439
Presente una queja en: www.tdi.texas.gov
Correo electrónico:
ConsumerProtection@tdi.texas.gov
Dirección postal: MC 111-1A, P.O. Box 149091,
Austin, TX 78714-9091
DTC Rev 0521
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ACCIDENTAL DEATH INSURANCE POLICY

PLEASE REVIEW YOUR APPLICATION

Please review the attached copy of your application. If anything is incorrect or misstated, you must inform us right

away. We issued your policy on the basis that all of the information shown in your application was correct and

complete. If it is not, your policy may be void.

30-DAY RIGHT TO REVIEW POLICY

You have 30 days from the date of its delivery to review your policy. If during that time you are not satisfied with your
policy, you may return it to us or to your agent, and we will promptly refund all premiums paid. We will consider the policy
never to have been issued.

GUARANTEED RENEWABLE TO AGE 80

Your policy is guaranteed renewable until you reach age 80 . This means you have the right to continue your policy until you
reach age 80 . Unless there has been a material misrepresentation , we cannot cancel your policy during that time as long as
you pay the required premium before the end of each grace period.

PREMIUMS CAN CHANGE

We may change the premium for your policy. However, we cannot make any premium change unless we make the same
change to all policies of this form issued to persons of the same class. We will give you 30 days advance written notice
before any premium change. Your premium will not increase during the first five years following the policy date.

This Is a Legal Contract Between You and Us.

READ YOUR POLICY CAREFULLY.

THIS IS AN ACCIDENT-ONLY POLICY WHICH DOES NOT PAY

BENEFITS FOR LOSS RESULTING FROM SICKNESS.

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TABLE OF CONTENTS PAGE

DEFINITIONS...................................................................................................................................................... 1

ACCIDENTAL DEATH BENEFIT....................................................................................................................... 1

COMMON CARRIER ACCIDENTAL DEATH BENEFIT................................................................................... 2

AUTO/PEDESTRIAN ACCIDENTAL DEATH BENEFIT................................................................................... 2

BENEFICIARY PROVISION............................................................................................................................... 2

DEPENDENTS PROVISIONS............................................................................................................................ 2

Eligibility........................................................................................................................................................ 2
Newborn Children and Adopted Children ................................................................................................... 3
When Dependent Child Insurance Ends .................................................................................................... 3
Spouse Conversion Privilege ...................................................................................................................... 3
Spouse Continuation of Coverage .............................................................................................................. 3

EXCLUSIONS..................................................................................................................................................... 4

TERMINATION................................................................................................................................................... 4

CLAIMS PROVISIONS....................................................................................................................................... 5

Notice of Claim............................................................................................................................................. 5
Claim Forms................................................................................................................................................. 5
Proof of Loss................................................................................................................................................ 5
Time of Payment of Claims.......................................................................................................................... 5
Payment of Claims....................................................................................................................................... 5

TERM OF COVERAGE...................................................................................................................................... 5

POLICY PROVISIONS....................................................................................................................................... 5

Consideration............................................................................................................................................... 5
Entire Contract and Changes ...................................................................................................................... 5
Time Limit on Certain Defenses.................................................................................................................. 6
Grace Period................................................................................................................................................ 6
Reinstatement.............................................................................................................................................. 6
Physical Examinations and Autopsy ........................................................................................................... 6
Change of Beneficiary................................................................................................................................. 6
Misstatement of Age.................................................................................................................................... 6
Legal Actions................................................................................................................................................ 6
Other Insurance with Us.............................................................................................................................. 6
Illegal Occupation......................................................................................................................................... 7
Unpaid Premium.......................................................................................................................................... 7
Conformity with State Statutes.................................................................................................................... 7

50AD-23952
DEFINITIONS

Shown below are the defined terms used in your policy. To make these terms stand out, they are italicized wherever they
appear in your policy.

Age 80 means the first policy renewal date that coincides with or next follows an insured person's 80th birthday.

Beneficiary means the person(s) or legal entity you named in your application or later written request to receive any
benefits under this policy or any attached rider in the event of your death.

Class means persons with the same policy form, issue age, gender, family status, and type of coverage as yours. Such
persons reside in the same geographic area of the state as you do.

Common carrier means an entity that is licensed primarily to transport passengers for hire in any public land, air, or water
conveyance.

Dependent child means your child or your spouse's child who is insured in accordance with the DEPENDENTS
PROVISIONS section.

Injury means bodily harm which:

(a) is the direct result of an accident or trauma that occurs while your policy is in force; and
(b) results in loss independently of sickness and all other causes (except for sickness caused by the injury).

Insured person means you and, if insured under this policy, your spouse or dependent child .

Material misrepresentation means the failure to disclose information you were requested to disclose on your application
which, if disclosed, would have caused us to deny issuing or reinstating your policy. Any material misrepresentation is
subject to the Time Limit on Certain Defenses provision.

Policy date means the date coverage is effective under your policy as shown on the policy schedule.

Policy renewal date means the date your policy's premium is due. The frequency of the policy renewal date will vary
depending on whether the premiums are paid on a monthly, quarterly, semiannual, annual, or other basis.

Primary insured means the person named as the Insured on the policy schedule.

Private automobile means a four-wheeled motor vehicle designed to carry passengers and travel on public streets and
highways. A private automobile does not include a vehicle intended for public transportation or for hire.

Spousemeans the person to whom you are legally married and who is insured under this policy in accordance with the
DEPENDENTS PROVISIONS section.

We, us, and our mean Mutual of Omaha Insurance Company.

You and your mean the person named as the Insured on the policy schedule, who is also the primary insured.

ACCIDENTAL DEATH BENEFIT

If, while insured under this policy, an insured person sustains an injury which results in death within 365 days following the
date of the injury, we will pay the Accidental Death Benefit shown on the policy schedule.

The accidental death benefit for your spouse will be 100% of the amount payable for the primary insured .

The accidental death benefit for a dependent child will be 20% of the amount payable for the primary insured .

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COMMON CARRIER ACCIDENTAL DEATH BENEFIT

Your policy contains a common carrier accidental death benefit if such benefit is shown as applicable on the policy schedule.
If the benefit is applicable, the following will apply:

If, while insured under this policy, an insured person sustains an injury while riding as a fare-paying passenger on a common
carrier which results in death within 365 days following the date of the injury, we will pay a common carrier accidental

death benefit. The common carrier accidental death benefit is shown on the policy schedule. This benefit is payable in
addition to the accidental death benefit.

A passenger does not include a person riding as an operator, pilot, or member of the crew.

AUTO/PEDESTRIAN ACCIDENTAL DEATH BENEFIT

Your policy contains an auto/pedestrian accidental death benefit if such benefit is shown as applicable on the policy
schedule. If the benefit is applicable, the following will apply:

If, while insured under this policy, an insured person sustains an injury:

(a) while driving or riding in any private automobile ; or

(b) when struck by any motor vehicle ordinarily operated on public streets and highways

and such injury results in death within 365 days following the date of injury, we will pay an auto/pedestrian accidental death
benefit. Any auto/pedestrian accidental death benefit is shown on the policy schedule. This benefit is payable in addition to
the accidental death benefit.

BENEFICIARY PROVISION

If you die as the result of an injury, we will pay any accidental death benefits:

(a) to your beneficiary ; or

(b) to your estate if no beneficiary is named or living.

If your spouse or a dependent child dies as the result of an injury, we will pay any accidental death benefits due:

(a) to you, if you are living; otherwise,

(b) to your estate.

You may change your beneficiary in accordance with the Change of Beneficiary provision.

DEPENDENTS PROVISIONS

Your eligible dependents are covered under this policy only if you apply for coverage for them, we approve the application,
and you pay the required premium.

ELIGIBILITY

Eligible dependents include:

(a) your spouse who is under age 80 ;

(b) any unmarried dependent child who is under age 25;
(c) any unmarried grandchild who is under age 25 and is a dependent of yours for federal income tax purposes;
(d) any adopted child or any child placed with you for the purpose of legal adoption, who also qualifies as a dependent
child under item (b); and

(e) any child of yours whom you are required to insure under a medical support order issued under Chapter 154, Family
Code, or enforceable by a court in Texas.

50AD-23952 Page 2
NEWBORN CHILDREN AND ADOPTED CHILDREN

Any of your children, your dependent child's children or children whom you are required to insure under a medical support
order issued under Chapter 154, Family Code, or enforceable by a court in Texas born while this policy is in force will be
automatically insured from birth for 31 days or until the first day of the second month following birth, whichever is longer.
Coverage for the newborn child will continue beyond the automatic coverage period without evidence of insurability if we
receive a written or verbal request prior to the end of such period. You will need to pay any additional premium for
dependent child coverage. Expiration of the automatic coverage period will not affect any claim incurred prior to the end of

such period. Coverage will be subject to all provisions of this policy applicable to dependent child coverage.

Any child you adopt while this policy is in force will be automatically insured for 31 days or until the first day of the second
month following the adoption or placement, whichever is longer. The automatic coverage period for such adoptive child will
begin on the earlier of:

(a) the date you are a party in a suit for which adoption is sought; or
(b) the date you have custody of a child under a temporary court order granting you conservatorship.

Coverage for the adopted child will continue beyond the automatic coverage period, without evidence of insurability, if you
send us notice of the adoption and pay any required additional premium before the end of such period. Continuous coverage
for the adopted child will end on the earlier of:

(a) the date placement is disrupted prior to legal adoption and the child is removed from placement; or
(b) the date coverage would otherwise end in accordance with your policy's TERMINATION section.

WHEN DEPENDENT CHILD INSURANCE ENDS

Coverage for a dependent child will end on the first of the following dates:

(a) the first policy renewal date on or after the date he or she reaches age 25;
(b) the date he or she gets married;
(c) the date he or she meets any of the conditions of the TERMINATION section.

If we accept the additional dependent premium for this policy after the last dependent child reaches age 25 or after we
receive notice that he or she is no longer a full-time student, coverage for such child will continue until the end of the period
for which premium has been accepted. If we accept premium without notice of marriage or notice that the last dependent
child is no longer a full-time student, it will be refunded.

If, on the date a dependent child's insurance would end because of reaching age 25, he or she is not capable of self-sustaining
employment because of an intellectual disability or physical handicap, and is chiefly dependent upon you for support and
maintenance, we will continue that child's coverage. Coverage will continue as long as your policy remains in force and the
incapacity continues. We may ask prior to the date coverage for a dependent child is to end whether or not he or she is
incapacitated. Unless you send us satisfactory proof of such incapacity within 60 days of our inquiry, we may terminate the
child's coverage under this policy.

SPOUSE CONVERSION PRIVILEGE

If your coverage ends due to a divorce and we are still offering this policy form for sale, we will issue your former
spouse's

spouse his or her own 50AD policy. Your former spouse must pay the premium for the new policy within 60 days after the
date of the divorce. If at the time your marital status changes we no longer offer this policy form for sale, this provision will
not apply and your spouse's coverage will terminate on the date of divorce.

SPOUSE CONTINUATION OF COVERAGE

Spouse coverage under this policy ends when your spouse reaches age 80 and this policy is still in force. If this policy
terminates because:

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 (a) you reach age 80 ;
(b) you die; or
(c) you cancel coverage for yourself;

your spouse can continue this coverage if he or she is under age 80 . To do so, your spouse must submit a request to become
the policy's new primary insured and pay the required premium within 60 days after the policy renewal date which next
follows the date your coverage ended.

EXCLUSIONS

Your policy pays benefits only for death resulting from injuries . We will not pay benefits for:

(a) death that occurs while this policy is not in force;

(b) death resulting directly or indirectly from disease or bodily infirmity;
(c) death resulting from an act of declared or undeclared war;
(d) death that occurs while serving in the armed forces;
(e) death caused by intentionally self-inflicted injury, while sane or insane;
(f) death caused by an insured person's suicide or attempted suicide, while sane or insane;
(g) death resulting from an insured person's commission or attempted commission of a felony;
(h) death resulting from an insured person's being intoxicated (as determined and defined by the laws of the jurisdiction
in which the loss or cause of loss occurred; for the purposes of this exclusion, the laws governing the operation of
motor vehicles while intoxicated will apply);
(i) death resulting from an insured person's being under the influence of any controlled substance (except for narcotics
given on the advice of a physician); or
(j) death resulting from a moving vehicle accident occurring while an insured person is engaged in a contest of speed,
organized or not.

TERMINATION

Your policy will end on the earliest of:

(a) the date we receive your written or verbal request to cancel this policy, or any future date you specify in your
request (in either case the grace period will not apply);
(b) the policy renewal date , if the renewal premium was not paid before the end of the grace period;
(c) the date you reach age 80 , unless your eligible covered spouse submits a request to become the primary insured ; or
(d) the date you die, unless your eligible covered spouse submits a request to become the primary insured .

Spouse or dependent child coverage under your policy will end on the earliest of:

(a) the date we receive your request to terminate your spouse's or dependent child's coverage (in which case the grace
period will not apply);
(b) the date of divorce;
(c) the date your spouse reaches age 80 ;
(d) the date dependent child coverage ends as described in the When Dependent Child Insurance Ends provision;
(e) the date your coverage ends; or
(f) the date your spouse or dependent child dies.

In the event of cancellation or death, we will promptly return the unearned portion of any premium paid. If we accept a
premium after an insured person reaches age 80 , coverage will continue for that person until the end of the period for which
premium was accepted.

Termination of coverage will not affect any claim for benefits for an injury sustained while your policy was in force.

50AD-23952 Page 4
CLAIMS PROVISIONS

NOTICE OF CLAIM

Written notice of a claim must be given to us within 20 days after a covered loss occurs or starts, or as soon as reasonably
possible. You may give the required notice or someone else may do it for you. The notice should include your name and
policy number. Notice should be mailed to us in Omaha, Nebraska.

CLAIM FORMS

When we receive your notice of a claim, we will send you forms for filing proof of loss. If we do not send you these forms
within 15 days of such notice, you can meet the proof of loss requirement by giving us a written statement of your claim. We
must receive this statement within the time given for filing proof of loss.

PROOF OF LOSS

You must give us written proof of loss within 90 days after the onset of such loss. If it is not reasonably possible for you to
give us written proof within the required time, we will not reduce or deny the claim for this reason if the proof is supplied as
soon as reasonably possible. In any case, proof must be given no later than 12 months from the time specified, unless you
were legally incapacitated.

TIME OF PAYMENT OF CLAIMS

We will pay benefits for a covered loss immediately upon receipt of proper written proof of loss.

PAYMENT OF CLAIMS

We will pay benefits to you, if you are living. In the event of your death, benefits will be paid to either your beneficiary or
your estate, in accordance with the BENEFICIARY PROVISION section.

If any benefits are payable to your estate, to a minor or any person not legally able to give a valid release, we may pay up to
$1,000.00 to any relative of yours whom we find entitled to the payment. If we make a payment in good faith, we will be
fully discharged to the extent of the payment.

TERM OF COVERAGE

Your coverage starts on the policy date at 12:01 a.m. where you reside. It ends at 12:01 a.m. where you reside on the first
policy renewal date . Each time you renew your policy by paying the premium within the 31-day grace period, a new term

begins when the old term ends.

POLICY PROVISIONS

CONSIDERATION

In consideration of the application and the first premium you paid, we have put this policy in force as of the policy date . That
date is shown on the policy schedule.

ENTIRE CONTRACT AND CHANGES

This policy is a contract between you and us. The entire contract consists of:

(a) the policy;

(b) the attached application;
(c) any supplemental applications made part of the policy;
(d) any riders; and
(e) any endorsements or amendments.

50AD-23952 Page 5

1126002A00
SC3Q_P230410616002000022 1120000000101000000001250
No change in this policy will be effective until approved by a company officer. This approval must be noted on or attached
to the policy. No agent can change this policy or waive any of its provisions. Any rider, endorsement, or application added
after the policy date which reduces or eliminates coverage under this policy will require your signed acceptance to be valid.

TIME LIMIT ON CERTAIN DEFENSES

After two years from the date a person becomes covered under this policy, only fraudulent misstatements in the application
can be used to void the policy or deny any claim for loss incurred after the two-year period.

After two years from the date of reinstatement, only fraudulent misstatements in the reinstatement application can be used to
void the policy or deny any claim for loss incurred that starts after the two-year period.

GRACE PERIOD

Your policy has a 31-day grace period. This means that if you do not pay a renewal premium on or before the date it is due,
you can pay it during the following 31 days. During the grace period your policy will stay in force.

REINSTATEMENT

Your policy will lapse if you do not pay your premium before the end of the grace period. If we accept a late premium
without requiring you to complete an application for reinstatement, your policy will be reinstated.

If we require you to complete an application, we will reinstate your policy as of the approval date. If we do not approve your
application within 45 days of the application date, we will reinstate your policy on the 45th day following the date of the
application, unless we have previously given you written notice of its disapproval.

Your reinstated policy will only cover losses incurred on or after the date of reinstatement that are due to injuries. In all
other respects, your rights and our rights will remain the same as before the policy lapsed, subject to any provisions noted on
or attached to the reinstated policy.

PHYSICAL EXAMINATIONS AND AUTOPSY

We have the right to have an insured person examined, at our expense, as often as reasonably necessary while a claim is
pending. We may also have an autopsy done, at our expense, unless prohibited by law.

CHANGE OF BENEFICIARY

Only you have the right to change the beneficiary . The beneficiary's consent is not required to change the beneficiary ,
surrender or assign this policy, or to make any other change in this policy.

To change a beneficiary , send us a written request. When we record and acknowledge that request, the change will be
effective as of the date you signed the request. The change will not apply to any payments made or other action taken by us
before recording.

MISSTATEMENT OF AGE

If the age of an insured person has been misstated, all benefits payable will be those which the premium paid would have
purchased at the correct age. If this policy would not have been available based on the correct date of birth, the insured
person will have no coverage, and we will refund any premiums paid.

LEGAL ACTIONS

You cannot bring a legal action to recover under this policy until at least 60 days after you have given us satisfactory written
proof of loss. You cannot bring a legal action more than three years from the date proof of loss is required.

OTHER INSURANCE WITH US

You can be insured under only one policy of this type with us at any one time. If you are insured under more than one such
policy, you must select the one that is to remain in effect. In the event of your death, your estate will make this selection.
We will return all premiums paid, minus any claims paid, for the policy you cancel.

50AD-23952 Page 6
ILLEGAL OCCUPATION

We will not pay benefits for any loss resulting from an insured person being engaged in an illegal occupation.

UNPAID PREMIUM

When we pay benefits for a claim under this policy, we may reduce those benefits by the amount of any premium then due
and unpaid.

CONFORMITY WITH STATE STATUTES

Any provision of this policy which, on its effective date, is in conflict with the laws of the state in which you reside on that
date is amended to conform to the minimum requirements of those laws.

50AD-23952 Page 7

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.
MUTUAL OF OMAHA INSURANCE COMPANY
MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175

RETURN OF PREMIUM BENEFIT RIDER

The premium you paid and the application you completed put this rider in force as of the Rider Date. This rider is made a
part of the policy to which it is attached. It is subject to all parts of your policy not in conflict with this rider. In the event of
a conflict between this rider and any other provision of your policy, this rider will control.

Rider Date (same as the policy date if no date is shown)

Rider Premium (included in the policy premium if no amount is shown)

RETURN OF PREMIUM BENEFIT

We will pay a lump sum return of premium benefit if your policy terminates for any reason other than your accidental death,
including, but not limited to:

(a) lapse of your policy because premium was not paid before the end of the grace period; and
(b) your non-accidental death.

The return of premium benefit will be a percentage of all the premiums you paid, minus the amount of any claims we paid
under your policy and attached riders. This percentage is based on the number of years this rider has been in force, as shown
in the table in the PERCENTAGE OF PREMIUM RETURNED section.

NOTICE REGARDING LAPSE AND REINSTATEMENT

If your policy lapses because you did not pay the required premium before the end of the grace period, we may, under
certain circumstances, reinstate your policy as described in the Reinstatement provision of your policy. This rider,
however, cannot be reinstated. If your policy lapses, we will automatically pay any return of premium benefit that may be
due. This rider will then terminate.

TERMINATION

This rider will terminate on the earliest of:

(a) the date we pay the return of premium benefit;

(b) the date we pay an accidental death benefit on any insured person ;
(c) the date your policy terminates; or
(d) the date we receive your written or verbal request to cancel this rider, or any future date you specify in your request.

0NA3M

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PERCENTAGE OF PREMIUM RETURNED

The following table lists the percentage of premium that will be returned. Any claims paid under your policy and attached
riders will be subtracted from this percentage of premium. We will calculate your return of premium benefit using this
formula:

(Premiums Paid) multiplied by (Percentage from Table) minus (Any Claims Paid) equals (Return of Premium Benefit)

Percentage of

The Rider Has Been Premium

In Force For Returned

1 year 0%
2 years 0%
3 years 0%
4 years 1%
5 years 4%
6 years 8%
7 years 12%
8 years 15%
9 years 18%
10 years 21%
11 years 23%
12 years 26%
13 years 29%
14 years 31%
15 years 34%
16 years 36%
17 years 38%
18 years 41%
19 years 43%
20 years 45%
21 years 49%
22 years 53%
23 years 57%
24 years 61%
25 years 65%
26 years 72%
27 years 79%
28 years 86%
29 years 93%
30+ years 100%

Mutual of Omaha Insurance Company

0NA3M
MUTUAL OF OMAHA INSURANCE COMPANY
MUTUAL OF OMAHA PLAZA, OMAHA, NE 68175

AVIATION EXCLUSION AMENDMENT RIDER

This rider is made a part of the policy to which it is attached. It is subject to all parts of your policy not in conflict with this
rider. In the event of a conflict between this rider and any other provision of your policy, this rider will control.

Rider Date (same as the policy date if no date is shown)

There is no additional premium for this rider.

AVIATION EXCLUSION AMENDMENT

The following exclusion is added to the EXCLUSIONS section of your policy:

We will not pay benefits for death resulting from flying in an aircraft unless sustained as a passenger (not as a pilot, operator,
or a member of the crew).

TERMINATION

This rider terminates when your policy terminates.

Mutual of Omaha Insurance Company

0NG6M
1129002A00
SC3Q_P230410616002000022 1420000000101000000001280
.
 1130002A00
SC3Q_P230410616002000022 1520000000101000000001290
 1131002A00
SC3Q_P230410616002000022 1620000000101000000001300
.
 1132002A00
SC3Q_P230410616002000022 1720000000101000000001310
.
 1133002A00
SC3Q_P230410616002000022 1820000000101000000001320
 POLICY SCHEDULE

POLICY NUMBER POLICY DATE FIRST RENEWAL DATE

50AD4-547600-96M APR. 10, 2023 MAY 10, 2023

INITIAL PREMIUM RENEWAL PREMIUM

$82.08 $82.08 MONTHLY **

POLICY BENEFIT SERIES 23952 041023 700 #E

INSURED

ACCIDENTAL DEATH BENEFITS PAYABLE AS SHOWN BELOW

PRIMARY INSURED $250,000.00 RONALD L SANDERS
SPOUSE $250,000.00 325 RAINTREE DR APT 29
DEPENDENT CHILD $50,000.00 TYLER TX 75703
COMMON CARRIER BENEFIT IS 1 TIMES THE ABOVE AMOUNTS
AUTO/PED BENEFIT IS 25% OF THE ABOVE AMOUNTS
THE PREMIUM INCLUDES AN ANNUAL POLICY FEE OF $50
50AD4-547600-96M
INITIAL PREM $82.08

SANDERS 1073830

ADDITIONAL COVERAGE AND POLICY ADJUSTMENTS SHOWN BELOW

(NOTE: INFORMATION MAY CONTINUE ON REVERSE - PLEASE READ)

**RENEWAL PREMIUM SUBJECT TO CHANGE.

BENEFICIARY-SEE POLICY
DEPENDENTS PRISCILLA 42, DAERON 14, ELIJAH 06
0NA3M RETURN OF PREMIUM RIDER
RIDER PREMIUM $23.45
0NG6M AVIATION EXCLUSION AMENDMENT RIDER

CLAIM INFORMATION CALL 1-800-775-1000 OTHER SERVICE QUESTIONS CALL 1-800-775-6000

 MUTUAL OF OMAHA INSURANCE COMPANY
HIPAA NOTICE OF PRIVACY PRACTICES FOR
PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Why You Are Receiving This Notice
This notice describes how Mutual of Omaha Insurance
Company and its affiliated companies (Mutual) protect
Protected Health Information related to your Health Plan
and how we use and disclose that information.
The Health Insurance Portability and Accountability Act
(HIPAA) requires us to:
- Maintain the privacy of your Protected Health
Information;
- Provide you with this notice of our legal duties and
privacy practices with respect to your Protected
Health Information; and
- Follow the terms of this notice.
If you reside in a state whose law provides privacy
protections more stringent than those provided by HIPAA,
we will maintain the privacy of your Protected Health
Information as required by your stricter state law. We are
required to maintain the privacy of your Protected Health
Information for 50 years following your death.
Definitions
Protected Health Information means information about
an individual that is created or received by Mutual that
either identifies the individual or, based on a reasonable
belief, could be used to identify the individual, and that
relates to:
- The past, present or future physical or mental
health condition of the individual;
- The provision of health care to the individual; or
- The past, present or future payment for the
provision of health care to the individual.
Health Plan is defined by HIPAA to include the following
individual and group insurance products: major medical,
Medicare supplement, hospital indemnity, long term care,
dental, specified disease (such as cancer) and pharmacy
benefit plans.
MC20368_0513
Use and Disclosure of Protected Health
Information with Your Written Authorization
We will not use or disclose your Protected Health Information
without your written authorization unless the use or
disclosure is described in this notice. If you give us written
authorization to use or disclose your Protected Health
Information, you have a right to revoke the authorization at
any time by writing to the contact listed at the end of this
notice. However, any action Mutual or others have already
taken in reliance on the authorization cannot be changed.
Use and Disclosure of Protected Health
Information without Your Written Authorization
For Payment
We may use and disclose your Protected Health Information
without your authorization if it is needed for payment
purposes. For example, we may use or disclose information
about your medical procedures and treatment to process and
pay claims, to determine whether services are medically
necessary or to preauthorize or certify services covered
under your Health Plan. We may also disclose your
Protected Health Information for payment purposes to a
health care provider or another "Health Plan" issued by a
different insurance company or HMO.
For Health Care Operations
We may use and disclose your Protected Health Information
without your authorization if it is needed for our health care
operations. Health care operations include our usual
business activities. For example, business management,
accreditation and licensing, peer review, quality improvement
and assurance, enrollment, underwriting, reinsurance,
compliance, auditing, rating, and other functions related to
servicing your Health Plan. However, we are prohibited from
using or disclosing genetic information about you for
underwriting purposes unless we are underwriting long term
care coverage.
To Individuals Involved in Your Care
In certain limited situations, we may, without your permission,
disclose your Protected Health Information, either before or
after your death, to a family member, other relative, your
close personal friend or any other person involved in your
health care. In these circumstances, we only disclose the
Protected Health Information that is directly relevant to that
person's involvement with your care or with the payment for
your care.
0234301A00
SC3Q_P230410616002000022 1920000000101000010010330
Without your permission, we may disclose your Protected
Health Information to a family member, your personal
representative or another person responsible for your
care to notify them of your location, general condition,
death or to assist any of these people in identifying or
locating you.
If you are present when we make a disclosure or are
otherwise available prior to the disclosure and have the
capacity to make health care decisions, we will only
disclose your Protected Health Information if:
- We obtain your agreement;
- Provide you an opportunity to object and you do
not; or
- We reasonably infer from the circumstances,
based on the exercise of professional judgment,
that you do not object to the disclosure
If you are not present, are incapacitated or it is an
emergency when we need to make such a disclosure, we
may make the disclosure if, in the exercise of our
professional judgment, we determine that it is in your best
interests to do so.
If you have designated a person to receive information
regarding payment of the premium on your long-term
care or Medicare supplement policy, we will inform that
person when your premium has not been paid.
We may also disclose limited Protected Health
Information to a public or private entity that is authorized
to assist in disaster relief efforts in order for that entity to
locate a family member or other persons that may be
involved in some aspect of caring for you.
To Our Business Associates
We may disclose Protected Health Information to an
affiliate or to a business associate outside of Mutual, if
they need Protected Health Information to provide a
service to us and have confirmed that they follow the
HIPAA rules relating to the protection of Protected Health
Information. Examples of these business associates
include our insurance agents, financial auditors, quality
accreditation services, actuaries and underwriting
support services, legal service providers, enrollment and
billing service providers, claim payment administrators,
information technology service or system providers and
collection agencies.
For Other Products and Services
We may contact you without your permission to provide
information regarding other health related benefits and
services that may be of interest to you. For example, we
may use and disclose your Protected Health Information
without your permission to tell you about our health
insurance products that could enhance or substitute for your
existing coverage, and about health related products and
services, such as case management or care coordination, that
may add value to you.
For Other Uses and Disclosures
We are permitted or required by law to make some other uses
and disclosures of your Protected Health Information without
your permission. Examples of these uses and disclosures
include:
- We may release your Protected Health Information if
required by law to a government oversight agency
conducting audits, investigations, or civil or criminal
proceedings.
- We may release your Protected Health Information if
required to do so by a court or administrative ordered
subpoena or discovery request. In most cases you will
have notice of such a release.
- If you receive your health coverage through a group
Health Plan, we may release your Protected Health
Information to your plan sponsor for their benefits
administration activities.
- We may release your Protected Health Information for
public health activities, such as required reporting of
disease, injury, birth and death and for required public
health investigations.
- We may release your Protected Health Information as
required by law if we suspect child abuse or neglect or
if we believe you to be a victim of abuse, neglect or
domestic violence.
- We may disclose your Protected Health Information to
the Food and Drug Administration if necessary to report
adverse events, product defects or to participate in
product recalls.
- We may release your Protected Health Information to
law enforcement officials as required by law to report
wounds, injuries or crimes.
- We may release your Protected Health Information if we
believe it is necessary to do so to arrange an organ or
tissue donation from you or a transplant to you.
- We may release your Protected Health Information to
coroners and/or funeral directors consistent with law.
- We may release your Protected Health Information for a
national security or intelligence activity or, if you are a
member of the military, as required by the armed
forces.
- We may release your Protected Health Information to
workers' compensation agencies if necessary for your
workers' compensation benefit determination. All other
uses and disclosures including those for marketing
purposes and disclosures that constitute the sale of
medical information require your written authorization.
 Your Rights
Right to Inspect and Copy Your Protected Health
Information
You have the right to inspect and receive a copy of your
Protected Health Information that is in a designated
record set. You may request your records be in paper
or electronic format. All requests for access to Protected
Health Information must be made in writing and signed
by you or your authorized representative. We may
charge you a fee for each page and an administrative
fee for processing your request. We will inform you of
the fee before we process your request. We may also
charge you for any postage costs associated with your
request. We may deny access to your Protected Health
Information for certain reasons. The reasons will be
made available in writing at the time of the denied
request. We will also provide you with information about
how you can file an appeal if you are not satisfied with
our decision. You may obtain an access request form
by contacting us, using the contact information at the
end of this notice. We do not keep complete copies of
your medical record. If you would like a copy of your
medical record, send your doctor a written request.
Right to Amend Your Protected Health
Information
You have the right to request that the Protected Health
Information we maintain about you be amended. We
are not obligated to make all requested amendments,
but will give each request careful consideration. All
amendment requests, must be in writing, signed by you
or your authorized representative, and must state the
reasons for the amendment request. You may obtain
an amendment request form by contacting us using the
contact information at the end of this notice. If the
amendment request is part of your medical record, you
will need to contact the doctor who wrote the record and
request a change. Once the medical record has been
changed, have your doctor send a copy to us for our
files.
Right to an Accounting of the Disclosures of
Your Protected Health Information
You have the right to receive an accounting of certain
disclosures we made of your Protected Health
Information during the six years prior to the date the
accounting is requested. All requests must be made in
writing, signed by you or your authorized representative.
Examples of disclosures we are required to account for
include those to state insurance departments, pursuant
to a legal process, or for law enforcement purposes.
Examples of disclosures not subject to such an accounting
include those made to carry out our payment or health care
operations, or those made with your authorization. Your
request must give the time period that you want to know
about. You may obtain an accounting request form by
contacting us, using the contact information at the end of this
notice. There will be no charge for the first accounting in any
12-month period. For additional accountings in any 12-month
period, you may be charged a fee. The fee will be a per-page
fee and an administrative fee. We will inform you of the fee
before we process your request. We may also charge you
postage costs associated with your request for additional
accountings during any 12-month period.
Right to Request Confidential Communications
You have the right to request that communications from us
regarding your Protected Health Information be sent by
alternative means or to alternative locations. For instance,
you may ask that messages not be left on voice mail or that
correspondence not be sent to a particular address. We are
required to accommodate your request if you inform us that
disclosure of all or part of your information could place you in
danger. You may request such confidential communication in
writing and may send your request to the contact identified at
the end of this notice.
Right to Request Restrictions on Use and Disclosure
of Your Protected Health Information
You have the right to request restrictions on some of our uses
and disclosures of your Protected Health Information for
medical treatment, payment, or health care operations by
notifying us in writing of your request for a restriction, mailed
to the contact identified at the end of this notice. Your request
must describe in detail the restriction you are requesting. We
are not required to agree to your restriction request, but will
attempt to accommodate your requests. We retain the right to
terminate an agreed-to restriction. In the event of a
termination by us, we will notify you of such termination, but
the termination will only be effective for Protected Health
Information we receive after we have notified you of the
termination. You also have the right to terminate, in writing or
orally, any agreed-to restriction by sending your termination to
the contact identified at the end of this notice.
Right to be Notified Following a Breach of Unsecured
Protected Health Information
You have the right to and will receive a notification if Mutual or
one of its business associates has a breach of information
security involving your unsecured Protected Health
Information.
0235001A00
SC3Q_P230410616002000022 2020000000101000000010340
 Complaints

If you believe your privacy rights have been violated,

you can file a complaint with Mutual or with the
Secretary of the U.S. Department of Health and
Human Services. To file a complaint with Mutual,
send the complaint in writing to the contact identified
at the end of this notice. There will be no retaliation
for filing a complaint.
Changes to This Notice

We are required to abide by the terms of this notice for

as long as it remains in effect. We reserve the right to
change the terms of this notice and to make a new
notice effective for all Protected Health Information
maintained by us, including Protected Health
Information, which was received by us before the
effective date of the new notice. If we do revise our
privacy notice, a copy of the new notice will be posted
on our web site at www.mutualofomaha.com and/or
sent to you if the changes are material.
Copies of This Notice

You may obtain a paper copy of this notice at any

time, even if you have already requested a copy by
e-mail or other electronic means. Please contact us
and we will mail it to you.
Effective Date

This notice is effective May 31, 2013.

Contact Information

If you have questions or need further assistance

regarding this notice, you may contact:
Mutual of Omaha Insurance Company
Attn: Privacy Office
Mutual of Omaha Plaza
Omaha, NE 68175
1-800-715-1423