secondary addressee designation
TRANSCRIPT
The Ohio National Life Insurance CompanyOhio National Life Assurance Corporation
Form 6420-sa-ca
Secondary Addressee Designation
Owner’s Full Name:
Insured’s Full Name:
Policy Number:
California applicants have the right to designate a secondary addressee to receive notice of policy lapse ortermination for nonpayment of premium. If you would like to make a designation, please complete theinformation below and return it with your application, or send it to us at P.O. Box 237, Cincinnati, OH45201-0237. If you do not wish to name a secondary addressee at this time, simply do not return the form.Note that this form will be provided on an annual basis should you reconsider.
I hereby designate the following individual to be the secondary addressee for the policy applied for:
First Name Middle Name (no initials, please) Last Name
Home Address City State Zip
Telephone Number:
Mailing Address (if different than above) City State Zip
Owner’s Signature Date
Application for Life Insurance Coverage
Form 6420-ca
LIFE INSURANCE
The Ohio National Life Insurance Company | Ohio National Life Assurance Corporation
Notice to the Proposed Insured and Owner ... A
Required Information for All Applications ..... 1
Life Plans/Riders/Benefits ................................. 3
Non-Medical Information ................................. 4
Additional Medical Information ...................... 5
Authorization and Mutual Agreements .......... 6Signatures required on all applications, pg. 6
Temporary Life Insurance Agreement and Receipt .................................... 7 Signatures required on pg. 7
Agent s Report ................................................... 8 Signatures required on pg. 8
Allocation of Production Credits ...................... 8b
APS Express Form .............................................. 9 (for attending physician statements)
Electronic Debit Authorization Agreement .... 10
As a general practice, we will not disclose personal information about you to anyone else without your consent, unless a legitimate business need exists or disclosure is required or permitted by law. You understand that by completing your insurance application you are disclosing personal information to any other party required to sign the application, (e.g., policyowner, spouse, additional insured, agent, etc.). You are entitled, upon request, to receive a more detailed statement of our information practices. You also have the right to ask about personal information which we may have in our files and the right to seek a correction of information you think is wrong.
Replacement of Existing CoverageIf you are considering replacing or causing a change to an existing life insurance policy or annuity contract, please tell our agent and answer questions in Section 7 in your application accordingly. Even if you are unsure about whether you will replace your existing coverage, indicating an intention to replace existing coverage may help you to receive information necessary for you to make an informed decision. If you do replace your existing life insurance coverage, the new policy will contain new suicide and contestable periods.
Backdating Your PolicyYou may request that the policy applied for be backdated to “save age.” This may allow you to gain the benefits of a lower age for purposes of determining the premium required for your policy. There are some costs, however, if you choose to backdate your policy. For the time period that the policy is backdated, the applicable premiums and/or cost of insurance charges are accumulated and deducted from your initial premium payment. In addition, even if you request that your policy be backdated to “save age,” no policy shall be in force unless all of the conditions in the Mutual Agreements section of your application have been met.
Electronic StorageWe will conduct business related to your application and life insurance policy electronically. We will also retain documentation, including your application, in an electronic format. Original documents, if received by Ohio National, will be destroyed according to our normal rules and practices.
Premium PaymentsIn your application, you may elect to pay premiums monthly (by automatic bank draft), quarterly, semiannually or annually. For whole life and term life insurance, we adjust the required annual premium by a modal factor in order to compensate for lost investment earnings and additional administrative costs. Therefore, if you elect to pay the required premium other than on an annual basis, your total out-of-pocket payments on an annual basis will be higher.
Ask our agent for assistance, or write or call us at Ohio National, Attention: Underwriting Division, P.O. Box 237, Cincinnati, Ohio 45201-0237. Telephone (513) 794-6100.
Form 6420-mib rev. 5/18 A
Notice to the Proposed Insured and OwnerThank you for your application.One of the prime objectives of Ohio National is to provide insurance at low cost. The underwriting process (evaluation of risks) is necessary not only to assure low cost, but also to assure that the fair share of the cost is contributed by each policyholder. Your application will be the primary source of information during the underwriting process. Therefore, it must be true, accurate, and complete. If the application is incomplete or it contains fraudulent statements or material misrepresentations, any claim made may be denied or coverage may be contested by Ohio National. The policy, if issued, will indicate under what circumstances it may be contested. You must inform Ohio National of a change to any answer in any part of the application before accepting delivery of the policy.
Information PracticesIn addition to your application, information from a number of sources is considered when we evaluate your application. We consider the results of your physical examination, if required, and any reports Ohio National may receive from doctors and hospitals who have attended you.
Information regarding your insurability will be treated as confidential. Ohio National or its reinsurers, may, however, make a brief report thereon to MIB, Inc. (MIB) a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is, MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Information for consumers about MIB may be obtained on its website at www.mib.com.
Furthermore, as part of the processing of your insurance application, we may request an investigative consumer report whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. You have the right to be personally interviewed if we order an investigative consumer report. Please notify our agent if this is your desire. You also have the right to receive a copy of the report and, by making a written request to Ohio National within a reasonable period of time, to receive additional, detailed information about the nature and scope of this investigation.
The Ohio National Life Insurance Company Ohio National Life Assurance CorporationP.O. Box 237, Cincinnati, Ohio 45201-0237(513) 794-6100
Please detach and deliver to the Proposed Insured/Owner immediately.
Applicant Copy
Authorization For Release Of Personal Health InformationThis authorization is designed to comply with the HIPAA Privacy Rule.
I hereby authorize any health plan, health care provider or health care clearinghouse (“Provider”) that has provided payment, treatment or services to the Patient or on his or her behalf to release to the persons or entities identified in Paragraph Number 1 any and all information it has about the Patient’s physical or mental health whether stored electronically, in paper, or in any other format. Paragraph Number 2 describes the class of persons or entities hereby authorized to release personal health information about the Patient. These persons or entities may disclose the information described in paragraph Number 3.
Proposed Insured (Patient’s Name) Additional Insured (Patient’s Name)
Date of Birth Social Security Number Date of Birth Social Security Number
1. The records and information will be disclosed to The Ohio National Life Insurance Company or Ohio National Life Assurance Corporation, (hereinafter “Ohio National”) P.O. Box 237, Cincinnati, Ohio 45201 and their contractors, employees, representatives, affiliates and assigns (hereinafter collectively referred to as “Recipients”) as necessary to fulfill the purpose of this disclosure.
2. Persons or entities hereby authorized to disclose personal health information about the Patient: Any health plan, physician, psychiatrist, psychologist, surgeon, health care professional, hospital, clinic, laboratory, pharmacy, pharmacist, pharmacy benefit manager, medical facility or medically related facility, insurance company, reinsurance company, insurance support organization (such as the MIB, Inc. [MIB]) or other health care provider, the Veterans Administration; a consumer reporting agency and employer.
3. Description of the information that may be disclosed: This authorization specifically includes the release of the Patient’s entire medical record and any other protected health information concerning the Patient including, without limitation, office notes, including those that describe a diagnosis, prognosis or response to treatment; results of all diagnostic tests; including, without limitation, genetic test results; genetic information; surgical notes; notes describing treatments provided, prescribed or recommended; history of prescriptions for pharmaceuticals; and all other information in your custody or control about any medical care or treatment provided to the Patient. This authorization specifically includes information concerning the diagnosis or treatment of Human Immunodeficiency Virus (HIV), sexually transmitted diseases, mental illness and the use of alcohol, drugs and tobacco. You may also disclose any financial, employment or personal information requested for insurance purposes.
The purpose of this disclosure is to evaluate an application for insurance or claim for benefits. I understand that the Recipients authorized to receive my personal health information are, when requesting such information, acting as a patient authorized representative and may attempt to access my personal health information in the most efficient manner possible, including electronic interchange through a Health Information Exchange or directly through my health care provider’s electronic health record system.
Ohio National may re-disclose information to reinsurance companies, to MIB, or their representatives, or to others who perform business or legal services related to the application or the policy or claim thereunder; in which case it may not be protected under federal privacy rules. Information will not be released to anyone else unless required or permitted by law or unless further authorized.
• This authorization is valid, as needed, for 24 months from the date it is signed. If this authorization has been submitted for the evaluation of a claim for benefits, however, it shall remain valid for the lesser of 24 months from the date it is signed or the duration of the claim. To the extent permitted by law, this authorization shall survive death.
• I agree that a photocopy or facsimile of this authorization may be used the same as the original.
• I have received Ohio National’s “Notice to the Proposed Insured and Owner” or “Notice of Information Practices.”
• I acknowledge that I have read this Authorization and received a copy of it.
• I understand that I may revoke this Authorization by sending written notice to Ohio National. Actions taken in reliance of this Authorization will not be affected, but no further actions will be taken in reliance of this Authorization after revocation is received by Ohio National. Revocation of this Authorization may result in the refusal to offer insurance coverage or pay benefits under a policy that has been issued.
• I further understand that my Providers cannot condition treatment, payment, enrollment or eligibility benefits on whether I sign this Authorization.
Signature of Patient (Proposed Insured)
Date
If signed on behalf of Patient (Proposed Insured), the signer is the Patient’s:
p Parent/Guardian of minor
p Other (specify)
Form 4020 rev. 1/19
Signature of Patient (Proposed Additional Insured)
Date
If signed on behalf of Patient (Proposed Additional Insured), the signer is the Patient’s:
p Parent/Guardian of minorp Other (specify)
Authorization For Release Of Personal Health InformationThis authorization is designed to comply with the HIPAA Privacy Rule.
I hereby authorize any health plan, health care provider or health care clearinghouse (“Provider”) that has provided payment, treatment or services to the Patient or on his or her behalf to release to the persons or entities identified in Paragraph Number 1 any and all information it has about the Patient’s physical or mental health whether stored electronically, in paper, or in any other format. Paragraph Number 2 describes the class of persons or entities hereby authorized to release personal health information about the Patient. These persons or entities may disclose the information described in paragraph Number 3.
Proposed Insured (Patient’s Name) Additional Insured (Patient’s Name)
Date of Birth Social Security Number Date of Birth Social Security Number
1. The records and information will be disclosed to The Ohio National Life Insurance Company or Ohio National Life Assurance Corporation, (hereinafter “Ohio National”) P.O. Box 237, Cincinnati, Ohio 45201 and their contractors, employees, representatives, affiliates and assigns (hereinafter collectively referred to as “Recipients”) as necessary to fulfill the purpose of this disclosure.
2. Persons or entities hereby authorized to disclose personal health information about the Patient: Any health plan, physician, psychiatrist, psychologist, surgeon, health care professional, hospital, clinic, laboratory, pharmacy, pharmacist, pharmacy benefit manager, medical facility or medically related facility, insurance company, reinsurance company, insurance support organization (such as the MIB, Inc. [MIB]) or other health care provider, the Veterans Administration; a consumer reporting agency and employer.
3. Description of the information that may be disclosed: This authorization specifically includes the release of the Patient’s entire medical record and any other protected health information concerning the Patient including, without limitation, office notes, including those that describe a diagnosis, prognosis or response to treatment; results of all diagnostic tests; including, without limitation, genetic test results; genetic information; surgical notes; notes describing treatments provided, prescribed or recommended; history of prescriptions for pharmaceuticals; and all other information in your custody or control about any medical care or treatment provided to the Patient. This authorization specifically includes information concerning the diagnosis or treatment of Human Immunodeficiency Virus (HIV), sexually transmitted diseases, mental illness and the use of alcohol, drugs and tobacco. You may also disclose any financial, employment or personal information requested for insurance purposes.
The purpose of this disclosure is to evaluate an application for insurance or claim for benefits. I understand that the Recipients authorized to receive my personal health information are, when requesting such information, acting as a patient authorized representative and may attempt to access my personal health information in the most efficient manner possible, including electronic interchange through a Health Information Exchange or directly through my health care provider’s electronic health record system.
Ohio National may re-disclose information to reinsurance companies, to MIB, or their representatives, or to others who perform business or legal services related to the application or the policy or claim thereunder; in which case it may not be protected under federal privacy rules. Information will not be released to anyone else unless required or permitted by law or unless further authorized.
• This authorization is valid, as needed, for 24 months from the date it is signed. If this authorization has been submitted for the evaluation of a claim for benefits, however, it shall remain valid for the lesser of 24 months from the date it is signed or the duration of the claim. To the extent permitted by law, this authorization shall survive death.
• I agree that a photocopy or facsimile of this authorization may be used the same as the original.
• I have received Ohio National’s “Notice to the Proposed Insured and Owner” or “Notice of Information Practices.”
• I acknowledge that I have read this Authorization and received a copy of it.
• I understand that I may revoke this Authorization by sending written notice to Ohio National. Actions taken in reliance of this Authorization will not be affected, but no further actions will be taken in reliance of this Authorization after revocation is received by Ohio National. Revocation of this Authorization may result in the refusal to offer insurance coverage or pay benefits under a policy that has been issued.
• I further understand that my Providers cannot condition treatment, payment, enrollment or eligibility benefits on whether I sign this Authorization.
Signature of Patient (Proposed Insured)
Date
If signed on behalf of Patient (Proposed Insured), the signer is the Patient’s:
p Parent/Guardian of minor
p Other (specify)
Form 4020 rev. 1/19
Signature of Patient (Proposed Additional Insured)
Date
If signed on behalf of Patient (Proposed Additional Insured), the signer is the Patient’s:
p Parent/Guardian of minorp Other (specify)
Return this to Home Office
The Ohio National Life Insurance CompanyOhio National Life Assurance Corporation
Post Office Box 237 Cincinnati, Ohio 45201-0237Telephone: (800) 366-6654
www.ohionational.com
Supplemental Authorization for Medical Records Access
Subject to my election below, I, the undersigned, attest that I have completed an application for insurance with Ohio National. I understand and acknowledge that, in connection with my application for life insurance with Ohio National, I have completed a HIPAA compliant authorization allowing Ohio National to access my medical records and other protected health information or private information concerning me (hereinafter collectively refer to as “Records”) from any hospital, physician, medical practitioner, psychiatrist, psychologist, social worker, mental health facility, physical/occupational therapist, chiropractor, rehabilitation facility, medical clinic, laboratory, pharmacy, pharmacy benefit manager, or insurance company (hereinafter collectively referred to as “Providers”), excluding any prior testing or results for HIV antibodies.
In order for Ohio National to timely underwrite my application for insurance, it is necessary for Ohio National to have immediate access to my Records. In furtherance of this request, I additionally grant The Ohio National Life Insurance Company or Ohio National Life Assurance Corporation, and their contractors, employees, representatives, affiliates and assigns (hereinafter collectively referred to as “Recipients”), the right to access all of my Records, including any and all protected health information, pursuant to the HIPAA Right of Access (45 C.F.R. Section 164.524). I hereby direct my Providers to immediately provide a copy of those records to the Recipients upon request by them. If a further authorization should be required by my Providers, I hereby grant Recipients the right to electronically sign, and initial, on my behalf, any additional authorizations necessary for my Providers to release my Records, including any protected health information, to the Recipients. This Right of Access shall be valid for two years from the date of my signature below, subject to any right I may have to revoke this authorization. In the event I do elect to revoke this authorization, I will separately notify my Providers in writing of such revocation, and until they receive such notice, they shall be fully protected in honoring this authorization and the Recipients’ request for a copy of my Records.
p I hereby elect to grant the supplemental authorization to obtain medical records pursuant to the above terms. Initials of Proposed Insured: _________________
p I hereby decline to provide this supplemental authorization.
Printed Name of Proposed Insured: __________________________________________________________
Signature of Proposed Insured: _____________________________________________________________
Date of Signature: ________________________
Form 6421-ca
2. Proposed Insured Employment Informationa. Occupation/Position b. Present Employer c. Type of Business
d. Address City State Zip
The Ohio National Life Insurance Company P.O. Box 237 Ohio National Life Assurance Corporation Cincinnati, Ohio 45201-0237Please print all answers. Life Insurance Application
1 Form 6420-ca
1. Proposed Insured Information
a. First Name Middle Name (no initials, please) Last Name
b. Home Address How long at this address?
City State Zip
c. Mailing Address (if different than home) City State Zip
d. Birth Date e. Issue Age (nearest birthday)
h. Social Security Number i. Driver’s License Number j. Expiration Date k. State Licensed
f. Do you elect to backdate the policy to Save Age? p Yes
g. p Male p Female - -
- -- - l. State of Birth
n. Are you a U.S. citizen? p Yes p No If “No,” currently a citizen of what country?
m. Country of Birth o. If non-US citizen, do you have a U.S. Green Card? p Yes p No
p. Net Worth q. Net Annual Income r. All Other Income
$ $ $
3. Owner Information
Complete this Section only if the policy will be owned by a person or entity other than the Proposed Insured. The Owner must sign page 6 of this application. If two or more persons are designated as Owner in any one category, their interests shall be joint and survivor.
a. Name of Owner or Trustee of Trust Relationship to Insured Birth Date
b. Address City State Zip
Full Name of Trust (if applicable) complete and attach Trustee Certification Form 6437. Attach a copy of the complete Trust documentation, including any amendments. Date of Trust
- -
- -
If the owner is a corporation, an authorized officer of the corporation must complete, sign and attach the Corporate Certification Form 3068.
c. Social Security Number/Tax ID d. Driver’s License Number e. Expiration Date f. State Licensed
- -
Form 6420-ca
effective 1/20
If there are additional Beneficiaries, please use and sign Form 6501.
4. Beneficiary Information
a. Primary Beneficiary or Name of Trustee Relationship to Insured
b. Contingent Beneficiary(ies) Relationship to Insured
Full Name of Trust (If Applicable) Date of Trust
- -
2 Form 6420-ca
6. Temporary Life Insurance Coverage
p Yes p No a. Has any person proposed for coverage been diagnosed or treated for heart attack, stroke or cancer within the last five years, or been advised to have any surgery which has not been performed? If 6a is answered “Yes,” the amount applied for exceeds $1 million, or age exceeds 70, no premium may be submitted, and 6b must be answered “No.”
p Yes p No b. Is premium submitted with the application? Amount remitted $
7. Other Coverage/Replacement Information
p Yes p No a. Are you currently applying for other life insurance? If “Yes,” provide details:
p Yes p No c. Does the proposed policy replace or cause a change in any existing individual life insurance policy or annuity contract?
If either 7b or 7c is answered “Yes,” list all types of insurance below, and indicate whether the proposed policy will replace or cause change in any existing life insurance policy or annuity contract. The “Important Notice: Replacement of Life Insurance or Annuities,” Form 6486, must be completed, signed and submitted with this Application.
Face Amount Will It 1035 Replacement Company Policy Number of Insurance Purpose Be Replaced? Exchange Date
p Yes p No p Yes
p Yes p No p Yes
p Yes p No p Yes
p Yes p No p Yes
p Yes p No p Yes
“Children” shall mean the lawful children of the Insured by birth or adoption.
p Yes p No b. Do you have existing individual life insurance policy(ies) or annuity contract(s)?
5. Payor Information
3. Owner Information (Complete only if policy is to be owned by other than the Proposed Insured. Signature Required on Page 6.)
a. Name b. Relationship to Insured c. Birth Date
d. Address City State Zip
Complete this section only if the Payor is different than the Proposed Insured or Owner.
- - - -
- -
e. Social Security Number/Tax ID f. Driver’s License Number g. Expiration Date h. State Licensed
effective 1/20
Form 6420-ca
Form 6420-ca
$
8. Whole Life Plansa. Plan of Insurance b. Face Amount
8. Term Plans
$
a. Plan of Insurance b. Face Amount
c. Dividend p Paid-Up Addition p Reduced Premium p Cash p Accumulate at Interest p 1-Year Term
d. Non-Forfeiture Option
p Extended Term Insurance
p Automatic Premium Loan (If no Non-Forfeiture Option is elected, the default option elected will be extended term insurance.) Please submit signed NAIC Illustration or Disclosure Form 6451.
9. Whole Life Plans
Life Plans
3
p GPT p CVAT
d. Death Benefit Type p A - Level p B - Increasing
10. Universal/Variable/Survivor Life Plans a. Plan of Insurance b. DEFRA Test c. Face Amount $
$ e. Planned Premium Payment
SSN:
13. Additional Insureds - Spouse & Children (by Birth or Adoption)
Full Name(s) Relationship* Gender Age Birth Date Height Weight Amount Ins. In Force
*If Spouse/Additional Insured, please provide State of Birth:
Premium Mode p Annual p Semi-Annual p Quarterly p Monthly (Bank Draft) p List Bill Group # ________________
p Government Allotment Branch of Government ________________________
Please submit signed NAIC Illustration or Disclosure Form 6451.
11. Premium Mode
Form 6420-ca
effective 1/20
12. Life Riders/Benefits (Riders are subject to availability in your state.)
a. p Additional Coverage Rider Spouse or Additional Insured (UL/Index UL)
$
$
g. p Guaranteed Insurability Option (Whole Life, Term, UL/Index UL)
h. p Accelerated Benefit Rider (Complete Form 2949 for Whole Life, Form 2929 for Index UL, or Form 2960 for Term)
i. p Lifetime Advantage Rider (Complete Form 2946) (Universal Life Only)
k. p Other Riders and Benefits:
e. p Single PUA Rider (Whole Life) $
$
Per Month
d. p Flex PUA Rider (Whole Life) (Submit Illustration)
$
$b. p Children’s Rider (Whole Life, Term, UL/Index UL)
c. p Level PUA Rider (Whole Life) (Submit Illustration)
f. p Waiver of Premium (Whole Life and Term) p Waiver of Premium (UL/Index UL)
$
j. p One Year Term Rider (Whole Life)
$
$
parachuting, mountain or rock climbing, bungee jumping, scuba diving, or other hazardous avocations? (If “Yes,” complete Form(s) 6256-B and/or 6133-A&B.)
p Yes p No h. within the last five years, been fined more than $100 for any moving (traffic) violation?
p Yes p No i. within the last five years, been charged with, but not acquitted of, the violation of any criminal law other than minor moving (traffic) violations?
p Yes p No j. any intention of traveling or residing outside the United States or Canada?
p Yes p No k. been placed on current active status in the Armed Forces, or expect to have active status in the near future? (If “Yes,” complete Form 6500.)
p Yes p No l. filed for bankruptcy within the last five years? If “Yes,” indicate type and date of discharge.
p Yes p No m. within the last five years, smoked cigarettes? If “Yes,” indicate the name of the Proposed Insured and date last smoked.
p Yes p No n. within the last five years, used other forms of tobacco such as cigars, pipe, chewing tobacco or snuff? If “Yes,” indicate the name of the Proposed Insured and date last used.
14. Non-Medical Information
p Yes p No a. Is all or a portion of the initial or future
premiums for the proposed policy being paid, directly or indirectly, by anyone other than the Owner and/or the Proposed Insured?
p Yes p No b. Are you borrowing in order to pay all, or
a portion, of the initial or future premiums, for the proposed policy from any person or entity other than the Owner or the Proposed Insured?
Has any Proposed Insured or Owner:
p Yes p No c. ever sold a policy or been involved in
any discussions about the possible sale or assignments of the policy applied for to a life or viatical settlement company or to another third party?
Does any Proposed Insured or Owner:
p Yes p No d. presently intend to assign or sell the life
insurance policy applied for to a life or viatical settlement company or to another third party?
Has any Proposed Insured:
p Yes p No e. ever applied for insurance or policy reinstatement which was declined, postponed, rated, ridered or modified?
p Yes p No f. within the last five years, engaged in or
plan to engage in flying as a pilot or crew member? (If “Yes,” complete Form 6256A.)
p Yes p No g. within the last five years, engaged in or
plan to engage in motorized racing, hang gliding, ballooning, sky-diving,
Details of “Yes” answers. Please identify the question and the name of the Proposed Insured to whom the answer relates.
4 Form 6420-ca effective 1/20
Form 6420-ca
5Form 6420-ca
Details of “Yes” answers. Please identify the question and the name of the Proposed Insured to whom the answer relates. Include all diagnoses as well as names and addresses of all medical practitioners.
p Yes p No 17. Is anyone proposed for coverage currently taking any prescription medication, or under treatment or observation by a medical practitioner?
p Yes p No 18. Has anyone proposed for coverage had a weight change of over 10 pounds in the last year?
19. Has anyone proposed for coverage ever had any of the following:
p Yes p No a) chest pain, high blood pressure, heart murmur, heart attack, stroke or other disorder of the heart or circulatory system?
p Yes p No b) any disease or disorder of the nervous system, paralysis, seizure disorder, dizziness or severe headaches?
p Yes p No c) shortness of breath, asthma, sleep apnea, bronchitis, emphysema, or any other respiratory disorder?p Yes p No d) hernia, ulcers, hepatitis, or any disorder of the stomach, liver, gallbladder, spleen, pancreas, intestines or rectum?
p Yes p No e) diabetes, sugar, protein or blood in the urine, stone or other disorder of the kidney, bladder, prostate, or reproductive organs?
p Yes p No f ) cancer, tumor, or cyst?
p Yes p No g) gout, arthritis, or disorder of the muscles or bones, including the spine, back or joints?
p Yes p No h) allergy or any disorder of the skin, eyes, ears, nose, throat, sinuses, larynx, thyroid or lymph glands?
20. Has anyone proposed for coverage ever:p Yes p No a) been diagnosed or treated for AIDS (Acquired Immune Deficiency Syndrome)?
p Yes p No b) received disability benefits or compensation, or a disability pension?p Yes p No c) used barbiturates, tranquilizers, narcotics, cocaine, marijuana, amphetamines, inhalants, anabolic steroids or hallucinogens; except as legally prescribed by a physician (if physician, other than yourself )?
p Yes p No d) been treated or advised to seek treatment for drug abuse or alcoholism?
p Yes p No e) had any disease or disorder of the breasts, disorder of menstruation, miscarriage or complications of pregnancy?
p Yes p No 21. To the best of your knowledge and belief, are you now pregnant?
22. Has anyone proposed for coverage, within the last five years, other than as noted above:
p Yes p No a) had a check-up, consultation, illness, injury, surgery, or been a patient in a hospital, clinic or sanitarium?
p Yes p No b) had an EKG, X-Ray or other diagnostic test? p Yes p No c) been advised to have a diagnostic test, hospitalization or surgery?p Yes p No d) been treated or received counseling for anxiety, depression, stress, mental or nervous disorder, or other emotional disorder?
15. Proposed Insured 16. Additional Insured
a. Height Weight a. Height Weight
b. Name and address of your personal physician. b. Name and address of your personal physician.
c. Date and reason last consulted. c. Date and reason last consulted.
17.-22. Additional Medical Information (All Insureds, Including Additional Insureds)
effective 1/20
Form 6420-ca
The applicant need not disclose any prior testing for HIV antibodies in answer to any of the following questions.
Signature required for all applications.
AUTHORIZATION to any physician; practitioner; hospital, clinic or other medical or medically related facility; health care provider; insurance company or reinsurance company; insurance support organization; the Veterans Administration; the MIB, Inc. (MIB); a consumer reporting agency; motor vehicle records facility and/or employer:In order to enable Ohio National Life to act upon my application for insurance or to decide if I qualify for benefits or coverage, I authorize you to give to Ohio National Life any and all information, records or knowledge which you have about the physical or mental condition of myself and any of my minor children who are to be insured. This authorization covers medical history, evaluation, tests, diagnosis, treatment or prognosis, including information about drugs, alcoholism or mental illness, and includes any financial, employment or personal information requested for insurance purposes.I authorize Ohio National Life to release information, including personal health information, to reinsurance companies, to MIB, Inc., or to others who perform business or legal services related to my application or the policy or claim thereunder. I further authorize Ohio National Life, or its reinsurers, to make a brief report of my personal health information to MIB, Inc. Information will not be released to anyone else unless required or permitted by law or unless further authorized by me.· This authorization is good, as needed, for 24 months from the date signed or while I have a claim, if longer.· I agree that a photocopy of this authorization may be used the same as the original.· I have received the Notice to the Proposed Insured and Owner.· I understand that I have the right to receive a copy of this authorization.
IT IS MUTUALLY AGREED THAT:
a. The statements and answers on this application and Part 2, Paramed Application, are true and complete to the best of my knowledge and belief. A copy of this application will be the basis of any policy issued.
b. By signing below, I acknowledge receipt of the Temporary Life Insurance Agreement given in exchange for my payment shown in Question 6 of this application; and I accept the terms and conditions of that Agreement.
c. Except as otherwise provided in the Temporary Life Insurance Agreement, or the Electronic Debit Authorization Agreement, if completed, no policy shall be in force unless and until: (1) it is delivered to me; (2) the full first premium is paid during the lifetime of all persons to be insured under the policy; and (3) to the best of my knowledge and belief the health of the Proposed Insured and the statements and answers in this application remain the same, without material change, as of the date of the policy delivery.
d. By accepting an insurance policy issued on this application, I ratify any corrections, additions or changes made by Ohio National. In those states where required, there can be no change in amount, age at issue, risk class, plan of insurance, or benefits, unless I agree to the change in writing.
e. No agent is authorized to make or change a contract of insurance for Ohio National, nor extend the due date for a premium payment, nor waive any of Ohio National’s rights or requirements.
Insurance Fraud Notice: The undersigned Proposed Insured, Owner and Agent represent that the Proposed Insured and Owner has read, or had read to him/her, the completed application and that he/she realizes that any false statement or misrepresentation therein may result in loss of coverage under the policy.
Signature of Proposed Insured
Signature of Spouse or Additional Insured
Signature of Parent if Insured is Child
Signature of Owner (if other than above)
Month Day Year
City State
I hereby certify that I have truly and accurately recorded on this application the information supplied by the Applicant and/or Proposed Insured(s) and that the responses stated herein are, to the best of my knowledge, true and accurate.
Signature of Agent
Print Agent Name
Authorization and Mutual Agreements
6Form 6420-ca effective 1/20
Form 6420-ca
Certification: Under penalties of perjury, I certify all of the following:1. The number shown on this form is my correct identification number (or I am waiting for a number to be issued to me), and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and3. a. I am a U.S. citizen or U.S. resident, alien, or b. A partnership, corporation, company or organization created or organized in the United States or under the laws of the United States, or c. An estate (other than a foreign estate), or d. A domestic trust (as defined under Regulations section 301.7701-7), and4. I am exempt from FATCA reporting.
When Insurance Begins: Subject to all terms and conditions of this Agreement, you will have life insurance for not more than 60 days beginning when, and if, all of the following conditions are met:
1. you are not over age 70; and
2. you have not been diagnosed or treated for heart attack, stroke or cancer within the last five years; and
3. you have not been advised to have any surgery which has not been performed; and
TEMPORARY LIFE INSURANCE IS NOT AVAILABLE UNDER ANY CIRCUMSTANCES IF THE APPLICATION IS FOR MORE THAN $1,000,000 OF LIFE INSURANCE WITH OHIO NATIONAL LIFE. YOU MUST BE INSURABLE.
4. you have truthfully completed and signed the Application for life insurance with Ohio National Life; and 5. you have taken all medical or paramedical exams and tests we require under our underwriting guidelines and practices, which may include an x-ray and an electrocardiogram (EKG); and 6. the first monthly premium for the policy as applied for has been paid to Ohio National Life by a means acceptable to us.
Exclusions: No life insurance under this Agreement is available: 1. under any rider for which the Applicant has applied; or 2. if death results from suicide or self-destruction; or 3. if death is proximately caused by a sickness, injury or condition for which a medical professional provided or prescribed treatment within one year prior to the date of the Application; or 4. if we find that you were not insurable as of the effective date of this Agreement under our underwriting guidelines and practices.
Amount of Insurance: The amount of life insurance provided by this Agreement is the Smallest of: (a) the amount applied for in the Application; or (b) the amount we will issue based on your income and assets according to our guidelines and practices; or (c) $1,000,000 minus the amount of all other life insurance coverage on you with Ohio National Life.
When Insurance Ends: Life insurance under this Agreement ends on the Earliest of: (a) 60 days after it begins; (b) the date the insurance policy applied for takes effect; (c) the date we offer a policy other than as applied for; (d) the date we decline, postpone or make incomplete the Application and mail notice of that decision to the Applicant and refund the premium payment; or (e) the date we mail the Applicant notice that coverage ends and refund the premium payment. We may end your coverage under this Agreement and refund the premium payment at any time.
Death of Proposed Insured: If you die while this Agreement is in effect we will pay the death proceeds in accordance with the beneficiary designation in the Application unless one of the Exclusions listed
above applies. If we pay a claim under this Agreement, we will retain from the proceeds one month’s premium for the amount of the claim at the rate for your sex and age at a standard smoker or standard non-smoker risk class based on our findings about your use of tobacco.
Changes in the Proposed Insured’s Health: This Agreement does not commit us to issue the policy applied for or any other policy. However, if we can find, based on our underwriting guidelines and practices, that you were a standard risk or better for life insurance as of the date your coverage began under this Agreement, then: (a) we will deliver the policy as approved without regard to any change in your health which occurs while this Agreement is in effect; and (b) we will offer you policy coverage in place of this Agreement to take effect the same date as insurance began under this Agreement. Any policy we offer may be different from the one for which you applied. It may be reduced in amount according to our guidelines and practices. If your health has changed, no life insurance policy will be issued for more than the amount of your temporary coverage under this Agreement.
Premiums; Refunds: The payment made to us with this Temporary Life Insurance Agreement will be applied to pay premiums due under any policy we issue to you. If no policy takes effect, and no claim is incurred, our only obligation is to refund your money. All refunds are without interest.
Definitions: The Application to which this Agreement relates includes the health questions you answered as part of any required medical or paramedical exam. “You” or “your” means the Proposed Insured, as identified on the Application and below. “We,” “our,” “us” or “Ohio National Life” means The Ohio National Life Insurance Company and Ohio National Life Assurance Corporation, One Financial Way, Cincinnati, Ohio 45242.
Date of Application (Part-1)
Receipt
NO AGENT OR BROKER HAS THE AUTHORITY TO APPROVE OR EXTEND TEMPORARY LIFE INSURANCE OR WAIVE OR CHANGE ANY TERM OR CONDITION OF THIS AGREEMENT. ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO “OHIO NATIONAL LIFE.” DO NOT MAKE YOUR CHECK PAYABLE TO THE AGENT OR LEAVE “THE PAYEE” BLANK.
We acknowledge receipt of your payment as shown below. Amount Received Date Signature of Agent
$
Detach and deliver to the proposed insured and owner.Temporary Life Insurance Agreement
Terms
p The Ohio National Life Insurance Company P.O. Box 237 p Ohio National Life Assurance Corporation Cincinnati, Ohio 45201-0237
Signature of Proposed Insured
Signature of Owner (if other than the above)
Form tia.l rev. 1/12 7
Agent’s Report and Checklist 7. List former addresses in the Remarks section on page 8b if at present residence less than five years.
p Yes p No 8. Are you aware of any information not disclosed in the Application which might affect the underwriting of the risk? If “Yes,” explain in Remarks section on page 8b.
p Yes p No 9. To the best of your knowledge and belief, will insurance applied for replace insurance issued by this or any other company? If “Yes,” list all policies to be replaced:
Complete for all applications.
p Yes p No 10. Are you aware of any agreement to finance the payment of premiums for the proposed policy in any way? If “Yes,” provide details in Remarks section on page 8b.
p Yes p No 11. Are you aware of any plan to sell or transfer the proposed policy to any person or entity? If “Yes,” provide details in Remarks section on page 8b.
Certification
I certify that I have accurately recorded all information given by the Proposed Insured(s) and Owner and my statements on this Agent’s Report are complete and correct to the best of my knowledge. I certify that I have reviewed and accurately recorded the identifying information of the Proposed Insured(s) and Owner from their respective drivers’ license or other identifying document(s). I certify that the responses stated herein are, to the best of my knowledge, true and accurate. The Insurer approved all product sales literature and/or material that I used with respect to the solicitation of the application for the policy. I left a copy of all such product sales literature and/or material with the applicant, including a printed copy of all such sales literature and/or material presented electronically. If Question 1 of the Department of Labor Supplement is answered “Yes” or the client is otherwise using distributions from an IRA or Qualified Plan to pay premiums, I further certify that, in accordance with applicable Department of Labor regulations, that the proposed sale of the applied for life insurance policy is in the best interest of the client and that I have made or will make the disclosures that are required for this transaction.
Date Signature of Agent
8Form 6420-ca
p Yes p No 1. Did you give the Proposed Insured and Owner a copy of the Notice to the Proposed Insured and Owner?
p Yes p No 2. Did you provide the Proposed Insured and Owner the Temporary Life Insurance Agreement and did you collect premium for the same?
p Yes p No 3. Did you have the Applicant sign and enclose copy of the NAIC illustration?
p Yes p No 4. How well-acquainted are you with the Proposed Insured? (Applicant, if Proposed Insured is under age 15.) p First Contact p Known Casually p Well-known p Relative; state relationship
p Yes p No 5. Did you personally see the person(s) proposed for coverage? If “No,” provide details in Remarks section on page 8b.
p Yes p No 6. Was any portion of application asked or translated in a language other than English? If “Yes,” provide details in Remarks section on page 8b.
$
$ $$
1. If total amount of coverage applied for is $5 million or more, please provide appropriate third party business financial data (balance sheet, profit and loss statement) or personal financial data (1040 or financial statement) and cover letter to explain the need and purpose and how the amount was determined.
2. Amount of life insurance on spouse:
3. If proposed insured is a minor please indicate amount of life insurance on the following:
Father Mother Siblings
Financial
effective 1/20
Form 6420-ca 8b
Required Demographic Information
Complete for all applications.
Remarks
Please provide any additional information or instructions that would assist in the underwriting of this application or issuance of the policy(s).
Purpose of Sale
Allocation of Production Credits
Print Agent Name(s) Agency Code Agent Code Percent
1st Agent
2nd Agent
3rd Agent
Allocation of Production Credit - Please Print
Agent Phone ____________________________ Agent Fax Number _____________________________
p Personal p Business p Other
Please provide details to purpose of coverage and how amount was determined.
Marital Status of the Proposed Insured
p Single p Married p Divorced p Widowed
Ages of children in household __________________________________________________________________________
Requirements
1. Indicate requirements ordered: p MD Exam
p Paramed Exam
p EKG
p X-ray
p Specimen p Blood Profile p Other: Five Paramed Examiners are: p APPS p Portamedic p EMSI p ExamOne p Healthmasters
2. Indicate risk class quoted: p Super Preferred p Preferred p Select Non-Smoker
p Non-Smoker p Select Smoker p Smoker
4. In the event a phone interview is requested indicate phone number you want us to use to reach the Proposed Insured:
p Work
p
Home
p
Other
3. Indicate Proposed Insured E-Mail Address:
effective 1/20
Form 6002 rev. 6/17
AUTHORIZATION to any physician; practitioner; hospital, clinic or other medical or medically related facility; health care provider; insurance company or reinsurance company; insurance support organization; the Veterans Administration; the MIB, Inc. (MIB); a consumer reporting agency; and/or employer:
In order to enable Ohio National Life to act upon my application for insurance or to decide if I qualify for benefits or coverage, I authorize you to give to Ohio National Life any and all information, records or knowledge which you have about my physical or mental condition. This authorization covers medical history, evaluation, tests, diagnosis, treatment or prognosis, and includes information about drugs, alcoholism or mental illness. You may also give Ohio National Life any financial, employment or personal information requested for insurance purposes.
Ohio National Life may release information to reinsurance companies, to MIB, Inc., or to others who perform business or legal services related to my application or the policy or claim thereunder. Information will not be released to anyone else unless required or permitted by law or unless further authorized by me.
· This authorization is good, as needed, for 24 months from the date signed or while I have a claim, if longer.· I agree that a photocopy of this authorization may be used the same as the original.· I have received the “Notice of Information Practices” or “Notice to the Proposed Insured and Owner.”· I understand that I have the right to receive a copy of this authorization.
If signing for someone, also check here and identify below.
p Parent/Guardian of minor(s)p Spouse/Representative of the Deceased Insuredp Other (specify)
Identify married woman’s maiden name, names of minor children, Insured’s name, or others to whom authorization applies.
Signature of Proposed Insured
Signature of Spouse or Additional InsuredDate
APS Express
Proposed Insured: SSN:
Address:
Agent: Agency:
Ohio National Financial Services Cincinnati, Ohio
Complete this Form along with HIPAA, Form 4020. Fax both Forms to the Underwriting Department.
Fax Number: 513-794-4510
Based on the following information, please order APS if needed.
Important: Please submit original of this form with the Application.
Proposed Insured’s Date of Birth:
Plan: Amount: $
Significant Medical Condition(s):
Date(s)/Reason(s) Physician Was Consulted:
Doctor:
Address:
Phone No.:
Proposed Insured’s Date of Birth:
Plan: Amount: $
Significant Medical Condition(s):
Date(s)/Reason(s) Physician Was Consulted:
Doctor:
Address:
Phone No.:
9
Form 4030 rev. 3/19
Policy Number(s): ______________________ Name: ____________________________________
Electronic Debit Authorization AgreementAs indicated below and pursuant to the following terms, I authorize Debit(s) for the Initial Premium and/or Regular Monthly Debits from the bank account listed below for each policy applied for and/or for the policy number(s) indicated above.
Debit(s) For the Initial PremiumI authorize debit(s) for the purpose of either (a) collecting the initial premium for the insurance policy(ies) applied for, or (b) collecting any premium in addition to that submitted with the application(s) that is necessary to put the insurance policy(ies) into force. The debit(s) will be made after approval of the application(s) for insurance for maximum amount not to exceed $1,000 per policy applied for, unless a different maximum is specified below. I understand and agree that by granting this authorization, no insurance policy applied for will otherwise be in force until the insurance application for such policy has been approved by Ohio National, the full first premium for such policy is paid during the good health of the proposed insured and the statements and answers in the insurance application remain the same, without material change, as of the date the full first premium for such policy is paid by a debit. I expressly acknowledge and agree that if the amount I have authorized below is insufficient to pay the full first premium by a debit for any policy applied for, no insurance coverage will be in force until the full first premium is paid for that policy.
Regular Monthly DebitsI authorize (a) monthly debits to pay the required monthly premium for the insurance policy(ies) applied for once the full first premium for such policy(ies) has otherwise been paid, and/or (b) monthly debits for the required premium and/or to reduce the loan balance for the policy number(s) indicated above. Ohio National will notify me in writing as to the date and amounts of the monthly debit. Thereafter, Ohio National will not provide separate notice of premiums due and debits will continue on a monthly basis while the policy(ies) remain in force. Ohio National will typically submit a draft to the bank one business day prior to the scheduled monthly debit, or later, if the scheduled monthly debit is on a Sunday or a holiday. In all cases, the actual deduction from the below listed account will occur one business day after the draft is sent. Ohio National will provide notice at least ten days before any change in the monthly debit amount to the address of the bank account owner, or if none is provided, to the address of the policy owner. The option of applying dividends to reduce premium will not be available unless that is the only dividend option specified in the policy.
Debit Authorized: ❑ Debit(s) for the Initial Premium ❑ Regular Monthly Debits
❑ Both Debit(s) for the Initial Premium and Regular Monthly Debits
______________________________ ___________________________ __________________________ Bank/Financial Institution Routing Number Account Number
Type of Account: ❑ Checking ❑ Savings
❑ Add to existing Debit on Policy Number(s): _____________________________________________________
Debit(s) for the Initial Premium Maximum Amount Authorized (Per Policy): $___________. If no amount is specified, Ohio National will be authorized to debit the required premium up to a $1,000 maximum per policy applied for. If the amount authorized is insufficient, a new authorization will be required for the amount necessary and pay the full first premium by a single debit.
This authorization may be revoked by verbal or written notice so long as such notice is received by Ohio National during regular business hours, at least one business day before the scheduled date of the debit. You may call us at 1-800-366-6654 to revoke this authorization. If any debit authorized hereunder is dishonored for insufficient funds or other reason, Ohio National will charge a returned debit fee of $25 or the maximum permitted by law, whichever is less, and all future debits will cease. In the event this authorization is revoked or if a debit is dishonored, any policy not yet in force will not otherwise go into force and any policy already in force may lapse unless the required premium is paid.
___________________________________________________ ____________________________________________Signature of Applicant/Policy Owner Date
___________________________________________________ ____________________________________________
One Financial WayCincinnati, Ohio 45242Telephone: 1-800-366-6654
The Ohio National Life Insurance Company Ohio National Life Assurance Corporation
Signature of Bank Account Owner(s) (if different) Printed Name of Bank Account Owner(s)
The Ohio National Life Insurance Company | Ohio National Life Assurance Corporation
Form 1305-A Rev. 12-21
Privacy Policies and Practices Ohio National Financial Services and its affiliated companies thank you for your trust and confidence. Ohio National is committed to providing you, our customer, with competitive insurance and annuity products and services to help you meet your changing needs. We are equally committed to protecting the private and personal information we collect and maintain about you. Federal law requires us to tell you how we collect and protect this information. Please read this notice carefully to understand what we do. Our privacy policies and practices are posted online at ohionational.com. If you wish to continue to receive a hard copy on an annual basis, you may do so by contacting us at 513.794.6100. Unless substantive changes are made or otherwise requested, the privacy policy will no longer be mailed to your home.
Collection of information We gather private and nonpublic personal information about you in order to provide you with our insurance products and services. The information we collect starts with the information you provide on applications and other forms, when you request services, and when you file a claim. Although you provide most of the information yourself, we may also ask others about you, including, (1) health care providers, (2) consumer reporting agencies in compliance with the federal Fair Credit Reporting Act, (3) your employer, business associates or advisers, (4) interviews with persons who have knowledge of your circumstances and (5) public records, including motor vehicle reports.
We only seek to collect and use personal information that is necessary and appropriate for the needs of our business. We may collect, use and share information that relates to your insurance or investment needs and objectives. Such information may include income, finances, Social Security number, credit history, credit scores, employment, health, habits, and other factors that relate to the insurance products or services we are providing. Federal law gives you, the customer, the right to limit only (1) sharing information regarding your creditworthiness for affiliates’ everyday business purposes, (2) affiliates from using your information to market to you and (3) sharing for non-affiliates to market to you.
Maintaining complete and accurate information on our customers’ records is important. You have the right to see and, if necessary, request a correction on your record. If you would like a copy of your record or if you believe that your record is incorrect or incomplete, please write or call us at Ohio National Financial Services, Attention: Underwriting Division, P.O. Box 237, Cincinnati, OH 45201-0237, telephone 800.366.6654.
Disclosure of information Federal law gives consumers the right to limit some but not all sharing of personal information. However, Ohio National does not disclose private or nonpublic personal information about our customers or former customers to anyone, except as described in this notice. We do not sell customer lists or any information about our customers. In order to service your policy or contract, we may disclose information about you to our affiliated companies, your insurance agent and, where applicable, your broker/dealer. We may disclose your information for our everyday business purposes to affiliates and non-affiliates that perform services
(including administrative and claims services) on our behalf. Before disclosing information to non-affiliated service providers, we require them to agree to keep the information confidential and use it only for the purposes we have authorized. We may also disclose information to affiliates and non-affiliates as required or otherwise permitted by law. This includes a routine filing, such as a Form 1099, to the Internal Revenue Service. Additionally, we may disclose information to protect against suspected fraud or in response to a valid subpoena or other legal process. If you have any questions about the disclosure of your personal information, please call us at 800.366.6654 or visit ohionational.com.
Protecting confidentiality of customer records Your files or records are made available only to our personnel or representatives who need access to the information in order to perform their assigned duties. We do not disclose information about your health, except when authorized by you or as explained to you in our “Notice of Information Practices” delivered at the time you applied for your policy or contract. To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. In order to protect the security, confidentiality and integrity of nonpublic personal information we have gathered and maintain about you, we maintain and monitor a comprehensive information security program that contains administrative, technical and physical safeguards. Additionally, we routinely review our policies and procedures, monitor our computer networks and test the strength of our security.
Affiliates If you applied with us for a variable life insurance policy or variable annuity contract, this notice covers the following affiliates in addition to those named above: Ohio National Equities, Inc. (a wholesale broker/dealer), The O.N. Equity Sales Company (ONESCO, a retail broker/dealer) and its subsidiaries, including O.N. Investment Management Company and Ohio National Insurance Agency, Inc.
Persons with disabilities We strive to ensure that every person has access to information related to our products and services, including this privacy policy. Please contact us if you would like this privacy policy provided in an alternative format and we will seek to meet your needs.
Do you need to do anything? You do not need to take any action in response to this notice of our Privacy Policies and Practices. Because we do not share your private or nonpublic personal information other than as described above, you do not need to “opt-out.” If, however, you want more information concerning our privacy practices, please contact us at Ohio National Financial Services, Marketing, One Financial Way, Cincinnati, OH 45242, telephone 513.794.6100, ohionational.com.
The Ohio National Life Insurance Company | Ohio National Life Assurance Corporation
Form 1305-A Rev. 12-21
Privacy Notice for California Residents Only
This Privacy Notice supplements our “Privacy Policies and Practices” and applies only to California residents (“consumers” or “you”). A copy of our Privacy Policies and Practices can be found at ohionational.com. This Notice is being provided to you to comply with the California Consumer Privacy Act of 2018 (“CCPA”) and to inform you of your rights and how to exercise those rights under the CCPA.
Your rights under CCPA The CCPA provides California residents with specific rights regarding their personal information, including the: (1) Right to Know and Access Your Personal Information — You have the right to request that we disclose certain information to you about our collection, disclosure, use and sale of your personal information over the past 12 months, including the right to request the specific pieces of personal information collected about you; (2) Right to Delete Your Personal Information — You have the right to request that we delete the
personal information that we have collected and retained about you; and (3) Right to Opt-Out of the Sale of Your Personal Information — You have the right to opt-out of having your personal information sold by us. Please note, however, that we do not sell personal information about consumers. Accordingly, you do not need to opt-out of the sale of your personal information.
Personal information we collect We collect personal information about consumers which is defined under the CCPA as information that identifies, relates to, describes, is capable of being associated with, or could reasonably be linked, directly or indirectly, with a particular consumer or household. In particular, within the last twelve (12) months, we have collected and disclosed for business purposes, the following categories of personal information about consumers:
Category Examples Identifiers Real name, alias, postal address, unique personal identifier, online identifier, IP address,
email address, account name, Social Security number, driver's license number, passport number, or other similar identifiers
Personal information categories listed in the California Customer Records statute (Cal. Civ. Code § 1798.80(e))
Name, signature, Social Security number, physical characteristics or description, address, telephone number, passport number, driver's license or state identification card number, insurance policy number, education, employment, employment history, bank account number, credit card number, debit card number, or any other financial information, medical information, or health insurance information
Protected classification characteristics under California or federal law
Age (40 years or older), race, color, ancestry, national origin, citizenship, religion or creed, marital status, medical condition, physical or mental disability, sex (including gender, gender identity, gender expression, pregnancy or childbirth and related medical conditions), sexual orientation, veteran or military status, genetic information (including familial genetic information)
Commercial information Records of personal property, products or services purchased, obtained, or considered, or other purchasing or consuming histories or tendencies
Biometric information Genetic, physiological, behavioral, and biological characteristics, or activity patterns used to extract a template or other identifier or identifying information, such as, fingerprints, faceprints, and voiceprints, iris or retina scans, keystroke, gait, or other physical patterns, and sleep, health, or exercise data
Internet or other similar network activity Browsing history, search history, information on a consumer's interaction with a website, application, or advertisement
Geolocation data Physical location or movements
Sensory data Audio, electronic, visual, thermal, olfactory, or similar information
Professional or employment-related information
Current or past job history or performance evaluations
Inferences drawn from other personal information
Profile reflecting a person's preferences, characteristics, psychological trends, predispositions, behavior, attitudes, intelligence, abilities, and aptitudes
Categories of sources of personal information For each category of personal information described above, we collect that information from the following categories of sources: (1) directly from consumers or their agents (for example, from documents consumers submit to us in order for us to provide them with products and services); (2) indirectly from consumers or their agents (for example, through information we collect about consumers from consumer reporting agencies, health care providers, government entities, etc. in the course of providing services to them); and (3) directly and indirectly from activity on our website (ohionational.com) (for example, from website usage details collected automatically).
Use and disclosure of personal information We disclose your personal information for business purposes to the following categories of third parties: (1) our affiliated companies; (2) service providers; (3) your agent; and (4) if applicable, your broker/ dealer.
For each category of personal information described above, we may use or disclose that information for the following business purposes:
• To provide you with products or to administer your policy or contract.
• To communicate with you as part of our business.
• For third parties to perform services on your policy or contract.
• For business research and analysis.
• As required or otherwise permitted by law.
• To respond to and resolve complaints.
• To protect against suspected fraud.
We will not collect additional categories of personal information or use the personal information we collect for materially different, unrelated, or incompatible purposes as described herein without providing you notice.
How to exercise your rights You (on behalf of yourself or your minor child), or a person registered with the Secretary of State and authorized by you to act on your behalf, may exercise your CCPA rights described above by submitting a Verifiable Consumer Request to us by calling 800.366.6654, visiting ohionational.com or writing to us at Ohio National Financial Services, Attn: Legal, One Financial Way, Cincinnati, OH 45242.
The request must provide sufficient personal information about you (for example, your date of birth, address, last four digits of your Social Security number, etc.) to allow us to match that information with the personal information we have already collected and retained about you, in order to verify your identity.
We cannot respond to your request if we cannot verify your identity or authority to make the request, or if we cannot confirm that you are the consumer whose personal information we have collected and retained. Making a request does not require you to create an account with us. We will only use the personal information provided in a request to verify your identity or authority to make the request.
Response time When possible, we will respond within 45 days of our receipt of your request. If we are unable to meet this deadline we will notify you that we need more time (up to 90 days). We may deny your request if an exemption or exception under the CCPA applies.
Non-discrimination We will not discriminate against you for exercising any of your rights under the CCPA. We will not: (1) deny you goods or services; (2) charge you different prices or rates for goods or services; (3) provide you with a different level or quality of goods or services; or (4) suggest that you will receive a different price or rate for goods or services or a different level or quality of goods or services.
Questions/additional information For questions or additional information on the CCPA, our Privacy Policies and Practices or this supplement thereto, you may contact us by calling 800.366.6654, visiting ohionational.com or writing to us at Ohio National Financial Services, Attn: Legal, One Financial Way, Cincinnati, OH 45242.
The Ohio National Life Insurance Company | Ohio National Life Assurance Corporation One Financial Way | Cincinnati, Ohio 45242 | 513.794.6100 | ohionational.com Post Office Box 237 | Cincinnati, Ohio 45201-0237
Form 1305-A 12-21 © 2019 Ohio National Financial Services, Inc.