eApp Training environment by Power Financial

Login

User Name *

Writing Number *

Password *

Welcome!

Click Next to start your application.

Client Personal Information

First Name *

Last Name *

SSN *

Street Address *

Apt/Unit Number

City *

State *

Phone Number *

Date of Birth *

Height (in inches) *

Weight (in lbs) *

Driver's License Number *

Coverage Details

Policy Type *

Term Options *

Coverage Amount ($) *

Ancillary Products

Please indicate if you would like to include any ancillary coverage options.

Terminal Illness

Critical Illness

Chronic Illness

Long Term Care

Accidental Death

Accidental Death Coverage Amount ($) *

MIB/HIPAA Authorization

Please review and sign below to authorize the retrieval of necessary health and underwriting data. By signing, you agree to our HIPAA and MIB authorization terms.

Client Digital Signature *

Health Questions

Tobacco Use *

Any pre-existing health conditions? *

Please provide details:

What medications are you taking? *

Diabetes? *

AIDS/HIV? *

Cancer? *

Anxiety/Depression? *

Beneficiary Information

Beneficiary Name *

Relationship *

Policy Offer

Banking Information

Bank Name *

Account Number *

Routing Number *

Review Application

Terms and Conditions: By reviewing this application, you confirm that all information provided is accurate and complete. Any misrepresentation may delay or cancel your policy. You also agree to the Electronic Signature Consent Form and supplemental forms required for processing this application.

I, , primary insured, have read and agree.

I, , Agent, have read and agree.

E-Signature

A. I have read the statements and answers provided in this application and affirm that they are true and complete to the best of my knowledge. I understand that the Company may rescind or cancel coverage if there is any material misrepresentation.

I, , confirm.

B. This application, including its appendices and supplemental questionnaires, forms the basis for any coverage issued. Coverage will not take effect until a policy is issued, delivered, and amendments are signed with the first premium paid. No agent or examiner may waive any requirements.

I, , confirm.

C. I agree to apply my e-Signature to all applicable areas of the application and supplemental forms.

I, , agree.

D. By signing below, I acknowledge receipt and acceptance of the current United of Omaha Agent Agreement, including any compensation schedules, and agree to be bound by its terms.

Signed City & Signed State *

Client Signature *

Agent Signature *