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)

CAPTCHA