AEP
Mutual of Omaha MA/PDP
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AEP
Mutual of Omaha MA/PDP
About Us
Contact Us
Find Out More (FAQs)
Meet the Team
Photo Library
Testimonials
Carriers
Carrier Selection
Electronic Apps
Forms & Materials
iGo e-App
Incentives & Trips
News
Webinars
Contracting
Existing Agents
Licensing Tools
New Agents
Marketing
Brochures
Email & Mail
Fact Sheets
Leads & Prospecting
Seminars & Webinars
Social Media
Websites
News
Industry Resources
The Resource (Blog)
Tips of the Trade
Products
Ancillary
>
Disability Insurance
Group Ancillary
Hospital Indemnity
Small Business Retirement Plans
Short-term Medical
Travel Insurance
Critical Illness
Dental, Vision & Hearing
Hybrid Life & LTC
Life & Annuities
>
Annuities
Final Expense
Life
Simplified Issue Term
LTC & Care Products
>
Long-Term Care
Home Care
Short-term Care
Medicare
>
Medicare Advantage
Medicare Supplement
Part D
Quoting
Quoting Tools
Underwriting
Tools
Agent Profile
Business Growth
Education & Training
Secure File Upload
Technology
Video Library
Client Information
*
Indicates required field
Name of Insured
*
First
Last
Date of Birth
*
Gender
*
Male
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Height
*
Enter as 5'7" format.
Weight
*
State
*
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Tobacco Use
*
Yes
No
If yes, date last used.
*
Type of Tobacco Used
*
Cigarettes
Cigars
Pipe
e-Cigarettes
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Hookah
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Occupation/Industry
*
Responsibilities/Duties
*
Annual Income
*
U.S. Resident?
*
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U.S. Citizen?
*
Yes
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Resident Country (if not U.S.)
*
Coverage Details
Monthly Benefit $
*
Existing Coverage $
*
Max Benefit
*
Yes
Existing Coverage Type
*
Individual
Group
Elimination Period # of Days
*
Elimination Period # of Days
*
Benefit Period # of Years
*
Benefit Period # of Years
*
Business Overhead Coverage $
*
Has client ever been declined or rated for insurance?
*
Yes
No
If declined or rated, please provide details, including company.
*
Medical Provider
Date Last Consulted
*
Reason for Visit
*
Current Medications
*
Diagnosis
*
Health Questions
Cancer
*
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No
Diabetes
*
Type 1
Type 2
Cardiovascular
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Heart
Stroke
High Blood Pressure
Age at Diagnosis
*
Age at Diagnosis
*
Other Conditions
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Mental/Nervous
Respiratory
Kidney
Gastrointestinal
Cancer Type/Location
*
A1C
*
Substance Abuse
*
Drugs
Alcohol
General Questions
Select any and all that apply.
*
Personal Bankruptcy
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Other Details & Concerns
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