Mutual of Omaha Retirement Services

Product Information

Request A Quote

Request A FiRM Report

Marketing Materials

Request A Quote

required fields

Requestor Information
Your Name		Please provide a name.
Your E-mail Address		Please provide an e-mail address.
Your Phone Number		xxx-xxx-xxxx Please provide a 10 digit phone number.

Employer Information
Company Name		Please provide a company name.
Address
City
State		Please select a state.
Zip		Please provide a 5 digit zip code.
Phone Number		xxx-xxx-xxxx
Fax Number		xxx-xxx-xxxx
E-mail Address

Producer Information ¹
Name		Please provide a name.
Company Name		Please provide a company name.
Address		Please provide an address.
City		Please provide a city.
State		Please select a state.
Zip		Please provide a 5 digit zip code.
Phone Number		xxx-xxx-xxxx Please provide a 10 digit phone number.
Fax Number		xxx-xxx-xxxx
E-mail Address		Please provide an e-mail address.

Plan Information
This Plan Is A		New Plan Takeover Plan Please make a selection.
Estimated Annual Contributions		Enter $ Please provide a numeric amount.
Current Plan Assets		Enter $ Please provide a numeric amount.
Total Assets That Will Be Invested Outside The Mutual Of Omaha Product		Enter $
Total Outstanding Participant Loan Amounts		Enter $
Estimated Number of Participants with Account Balances		Please provide a numeric amount.
Plan Type		Please select a plan type. sp - requires special pricing
Pricing Option		Full Service TPA Please make a selection.

IMA Option		Please select a IMA Option.
Asset Charge
1st Year Deposit Compensation
Trail Compensation
Special Pricing ²		Yes No

Proposal Information
Select Format		Please select a format.
How Many Printed Copies of The Proposal Are Needed?
Date Proposal Needed		³ Please make a selection.
E-mail Address to Send Proposal
Mail proposal to		Producer New Address Please make a selection.

For Overnight Delivery ³
Carrier Name
Account Number

Comments

¹	Agents are required to be both properly licensed and appointed prior to selling this product. If you need assistance, forms or additional information regarding the appointment process, contact the Sales Desk at 877-401-SALE (7253).
²	Available if reimbursement of surrender charges from prior carrier is being requested or if plan type requires special pricing. Please complete takeover information above and specify pricing results you are looking for in "Comments".
³	Printed proposals will be sent via two-day delivery unless you supply your carrier name and account number.

Mutual of Omaha Insurance Company. All rights reserved.

Investment options are offered through a group variable annuity contract (Forms 902-GAQC-09 or 902-GAQC-09(CT) or 902-GAQC-09(OR)) underwritten by United of Omaha Life Insurance Company for contracts issued in all states except New York. United of Omaha Life Insurance Company, Omaha, NE 68175 is not licensed in New York. In New York, Companion Life Insurance Company, Hauppauge, NY 11788 underwrites the group variable annuity (Form 900-GAQC-07(NY)). Each company accepts full responsibility for each of their respective contractual obligations under the contract but does not guarantee any contributions or investment returns except as to the Guaranteed Account and the Lifetime Guaranteed Income Account as provided under the contract. Neither United of Omaha Life Insurance Company, Companion Life Insurance Company, nor their representatives or affiliates offers investment advice in connection with the contract.

AFN40101-643_0411