EA Forms Last Audited:  1/11/2014

Mutual of Omaha Forms

Form Number Revision Date

Form Name

(Links to Plan Source Library)

Internal Use
MUG6730-FS N/A WA Enrollment Form RA IA
LUGA1234 3/03 Application for Group Life Insurance RA IA
N/A N/A Life/AD & D Enrollment Form RA IA
N/A N/A Enrollment Form RA IA
N/A N/A  Voluntary Life Enrollment RA  
LUGA294 6/03 Application for Group Insurance - Disability RA IA
FS12222 8/12 Proof of Death Form (Life Claim) EA  
MUG6774 3/10 Group Benefit Service Application for Accidental Death Benefits RA  
MUG1710 3/10 Group LTD Claim (Mutual and United) RA  
UG2852 N/A United LTD Claim RA  
MUG6110A 3/29/10 STD Claim Form RA  
RPD539 N/A Designation of Beneficiary EA  
M20392 1/00 Employers Statement for Disability Benefits RA  
M20722 12/09 Attending Physicians Statement EA  
M20410 1/00  Policy Owner's Continuance of Disability Report RA  
MGA2005 12/11 Dental Claim EA  
MG350 8/03 Vision Claim RA  
MUG6582 N/A Employee Termination Report RA  
Link directly to the forms section of Mutual of Omaha's website



Please be advised that the forms in the PlanSource Library are only as current as the forms on the carrier’s web sites.  More and more carriers are requiring a user ID and password to access the forms section of their site, so it may delay PlanSource access to updated forms.  To access the most up to date forms, users may need to register with the carrier to obtain a login. 


Please note:  Any form in the PlanSource Library that is coded "RA" means that we are unable to locate the form on the carrier's website.  You may need to contact your carrier representative or broker to obtain the most current form.

If you can't find the form that you're looking for, please contact your insurance broker or HR Administrator.