Fill and Sign the Cook County Assessor Owner Lessee Verification Affidavit Form

Product Overview Standard Provisions Benefit Schedule • Flat • Options from 1x to 5x annual salary Plan Maximums (Based on Group Size) • Options from $10,000 to $500,000 • Other options available Guarantee Issue Limits (Based on Group Size) • Options from $10,000 to $500,000 • Other options available Reduction Schedule Basic Term Life • Age 65: 65 percent • Age 70: 45 percent • Age 75: 30 percent • Age 80: 20 percent • Age 85: 15 percent • Age 90: 10 percent • Other options available Voluntary Term Life • Age 70: 65 percent • Age 85: 20 percent • Age 75: 45 percent • Age 90: 15 percent • Age 80: 30 percent • Other options available Living Care Benefit (Employee and Spouse) • Benefit options from 25 to 80 percent • Benefit maximums from $25,000 to $500,000 Conversion Option to convert to individual whole life policy Life Waiver of Premium – Definition of Disability • Any Occupation • 2-year Own Occupation, followed by Any Occupation thereafter Waiver of Premium – Elimination Period Options from 3 to 12 months Waiver of Premium – Termination Date • Age 65, 70 or Social Security Normal Retirement Age • Other options available Layoff or Leave of Absence • Coverage terminates end of month following layoff or leave of absence • Option to extend coverage for 9 months from layoff, leave of absence, or approved sabbatical Annual Salary Increase 20 percent annual salary increase without requiring evidence of insurability, once past the Guarantee Issue Limit Coverage Type 24-hour Life and AD&D coverage Optional Provisions and Services Portability Employees can port coverage at affordable group rates; standard feature with VTL Additional AD&D Benefits (Options available in suites or individually) Travel Suite • Seatbelt Benefit – pays an additional 10 percent to max $50,000 • Airbag Benefit – pays an additional 10 percent to max $50,000 • Common Carrier – doubles the benefit if death or injury in public transportation • Repatriation – pays $5,000 for transportation of remains Family Suite • Spouse Education – pays to a maximum of $3,000 for spouse education and job training • Child Education – pays an additional 5 percent to a maximum of $5,000 for dependent child education • Child Care Center – pays 2 percent of principal sum to a maximum of $5,000 for eligible child care expenses • Continuation of Coverage – spouse coverage remains in force, 20 percent to a maximum of $50,000 after death of employee Catastrophe Suite • Paralysis – pays an additional benefit if injury results in paraplegia, hemiplegia, quadriplegia, triplegia, or uniplegia • Home Alteration – pays an additional 10 percent to a maximum of $10,000 for modifications to residence or vehicle • Coma – pays an additional 3 percent per month to a maximum of $5,000 monthly benefit for 11 months • Hospital Confinement – pays an additional benefit while hospitalized • Felonious Assault – pays an additional 10 percent to a maximum of $20,000 if injury results from assault Travel Assistance Services Assistance provided by third party vendor if employee travels outside the country or is 100 miles from home Employee Assistance Program • Basic Plan includes telephonic and Web-based services • Comprehensive Plan includes telephone and Web-based services, face-to-face visits and many other features Annual Increase Allowance Employees may increase their VTL coverage amount by $10,000 each year without providing evidence of insurability Cost Sharing Options Cost Sharing • • • • Non-contributory: 100 percent employer paid Contributory: employer and employee cost sharing Voluntary Term Life: 100 percent employee paid Flexible benefits and Section 125 available This insurance plan overview is not intended to provide a complete description of coverage. Benefits may not be available in all states. Not all features apply to voluntary products. Some exclusions, limitations and reductions may apply. Please contact your Mutual of Omaha representative for specific product details and policy provisions. Term life and AD&D insurance is underwritten by United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175. United of Omaha Life Insurance Company is licensed in every state except New York. Term Life Policy Form Number: 7000GM-C-EZ 2001. AD&D Policy Form Number: 7000GM-M-EZ 2001.