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Fill and Sign the If You Need Assistance Completing This Application Please Ask an Office of Public Assistance Staff Member Coverageforall Form

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Companion Life Insurance Company A Mutual of Omaha Company Whole Life Guaranteed Easy-to-apply-for whole life insurance protection Help protect your family’s financial security Having adequate life insurance coverage can protect your family from the burden of funeral and burial expenses, medical costs, outstanding debt, probate or taxes. The benefits are paid directly to the beneficiary you specify – to help meet expenses that might otherwise be a serious burden for your family. Guaranteed Coverage to Meet Your Needs Whole Life Guaranteed is affordable and easy-to-apply-for life insurance protection. It’s designed to help meet expenses, while protecting assets for future needs such as your children’s or grandchildren’s college educations or trust funds. As an addition to existing coverage or as an additional policy, Whole Life Guaranteed is part of our well-rounded life insurance portfolio designed to meet your needs. Features Modified Death Benefit for the First Two Years During the first and second policy years, if death results from sickness or other natural causes, the death benefit payable will equal 120 percent of the premiums paid. If death results from accidental bodily injury, the full death benefit will be paid. If the policy is issued as a replacement of another Companion Life Insurance Company policy and the replaced policy is terminated, the exclusion period for suicide will be measured from the issue date of the replaced policy. Permanent Protection Since Whole Life Guaranteed is permanent life insurance that expires at age 100, if the Insured is still alive at that point, the face amount, minus any outstanding policy loans and loan interest, will be paid. Policy Exclusions n Guaranteed acceptance for ages 50-75 n Cannot be canceled for any reason, as long as premiums are paid The policy’s face amount will not be paid if the Insured’s death results from suicide within two years of the date of issue. Instead, we will pay the sum of premiums paid since issue minus any loan not repaid. n Guaranteed protection to age 100 Premium Modes (modal factors) n Available in face amounts of $5,000 to $20,000 n Simple application process n No medical health examination required Annual (1.00) Semiannual (.50) Quarterly (.25) Monthly BSP (.0833) n No health questions to answer n Builds cash value n Rates never increase with age n Benefits never decrease n Benefits paid to your beneficiary income tax free, under current federal tax laws n Premiums payable monthly through your bank account, or quarterly, semiannually or annually n Coverage available for spouse YC1876_1007 Policy Fee $12 per year Since this policy is issued with no medical underwriting, the premium rates charged include an extra mortality risk charge. If you are healthy enough to qualify as a “standard” risk, premiums would likely be lower if you applied for a fully underwritten policy. Underwritten by: Companion Life Insurance Company Home Office: Lynbrook, NY 11563 mutualofomaha.com Policy form 826Y-0505

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