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2024
OEP
Co-op Reimbursement Request form
Request OEP Co-Op Reimbursement
Agent/Agency Name
(Required)
Phone Number
(Required)
Email
(Required)
Carrier Campaign:
Estimated App Counts per Carrier
Amount of Co-Op per Carrier
aetna-checked
Aetna
aetna-app-estimate
aetna-co-op-amount
anthem-checked
Anthem
anthem-app-estimate
anthem-co-op-amount
bcbs-checked
BCBS TN
bcbs-app-estimate
bcbs-co-op-amount
cigna-checked
Cigna
cigna-app-estimate
cigna-co-op-amount
devoted-checked
Devoted
devoted-app-estimate
devoted-co-op-amount
humana-checked
Humana
humana-app-estimate
humana-co-op-amount
wellcare-checked
Wellcare
wellcare-app-estimate
wellcare-co-op-amount
Agents in Hierarchy that will be receiving or being supported by co-op from this request
(Required)
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