2024 AEP Co-op Reimbursement Request form

Request AEP 2024 Co-Op Reimbursement

Agent/Agency Name(Required)

Phone Number(Required)

Email(Required)

Carrier Campaign:

Estimated App Counts per Carrier

Amount to Co-Op per Carrier

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Aetna

aetna-app-estimate

aetna-co-op-amount

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Anthem

anthem-app-estimate

anthem-co-op-amount

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BCBS TN

bcbs-app-estimate

bcbs-co-op-amount

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Cigna

cigna-app-estimate

cigna-co-op-amount

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Devoted

devoted-app-estimate

devoted-co-op-amount

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Humana

humana-app-estimate

humana-co-op-amount

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Wellcare

wellcare-app-estimate

wellcare-co-op-amount

Markets Targeted (Cities/Counties, States)(Required)

How Will These Funds Be Utilized to Create Membership?(Required)

Agents in Hierarchy that will be receiving or being supported by co-op from this request(Required)

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