Page 8 - Mutual of Omaha Sample App 022017

United of Omaha Life Insurance Company
A Mutual of Omaha Company Producer’s Report
(Must be completed by the Producer who obtained the application on the Proposed Primary Insured named below.)
1. Proposed Primary John D Smith
Insured Full Name ______________________________________________________________________________________
First Name
2. Please Note: A recent mortgage is not required for issuance of this policy.
Initial
Has the Proposed Insured purchased a home or refinanced a home within the last 2 years? ........................... ■ Yes ■ No
Last Name
If “Yes,” then complete the remainder of Question 2
Approximate Mortgage Loan Amount $ ______________________________
185Q,0u00ken Loans
ic
_
If “Yes,” explain below ..... ■ Yes ■ No ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
__
_
_
___
_
_
_
_
____________________________________________________ 3. Have you, the producer, observed or are you aware of any additional information that may affect the issuance of this policy?
Mortgage Loan Financial Institution Name __
_
L8359