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Agent Client Referral
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Agent Client Referral
Client Referral
Please fill out the form below to complete your Client Referral.
Have you completed your individual OCI agreement?
*
Yes
No/Unsure
Referring Agent Name:
*
Referring Agent Email
*
Agency Affiliation
*
Other, Please List
AIMCOR/EIG
Ameritas Investment Corporation
American Family
Carson Group
Farmers Insurance
Michigan Farm Bureau
Missouri Farm Bureau
Modern Woodmen
Shelter Insurance
Please select Other if not listed.
Other, Please List Agency Name:
Are you the principal of the agency
*
Yes
No
Name of Agency
Agency Name:
Client Name
*
First
Last
Client City
*
Client State
*
Alabama
Arizona
Arkansas
Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
South Carolina
South Dakota
Tennessee
Texas
Utah
Washington
Wisconsin
Wyoming
Client Zip Code
*
ZIP Code
Client Phone Number:
*
Client Email:
*
In cases where we are not able to reach the client by phone, an email will be sent to the client with the assigned OCI representative's contact information.
Coverage Type
*
Individual/Family Health (Under age 65)
Short Term Health
Dental/Vision
Medicare
Life
Long-Term Care
Annuity
Group Medical
Group Ancillary
Worksite
Disability
Other
Coverage Type
*
Individual/Family Health (Under age 65)
Short Term Health
Dental/Vision
Medicare
Life
Long-Term Care
Annuity
Group Medical
Group Ancillary
Worksite
Disability
Other
Client Birthdate
*
MM slash DD slash YYYY
Annuity Amount
Annuity Type
Coverage Type
*
Individual/Family Health (Under age 65)
Medicare
Life
Annuity
Group Medical
Group Ancillary
Worksite
Disability
Long Term Care
Coverage Type
*
Individual/Family Health (Under age 65)
Medicare
Life
Annuity
Group Medical
Group Ancillary
Worksite
Disability
Coverage Type
*
Individual/Family Health (Under age 65)
Short Term Health
Medicare
Disability
Coverage Type
*
Life
Annuity
Group Ancillary
Disability
Coverage Type
*
Group Ancillary
Medicare
Disability
Does your client make over $100,000?
No
Yes
Coverage Type
*
Individual Health
Disability
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
LONG-TERM CARE NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Long-Term Care.
LONG-TERM CARE NOTE: Based on the information you have provided, please use the link on your
webpage
to refer for full details on Long-Term Care.
OTHER PRODUCTS:
For all other products to refer go to American Family's web page:
https://www.ociservices.com/amfam-products/
. Thank you!
Has the client recently been declined for life insurance?
*
Yes
No
Based on the information provided. Please visit the
Shelter Decline Page
for further instructions
Has the client recently been declined for life insurance?
*
Yes
No
Based on the information provided. Please visit the
American Family Decline Page
for further instructions
Has the client recently been declined for life insurance?
*
Yes
No
Based on the information provided. Please visit the
Michigan Farm Bureau Decline Page
for further instructions
Has the client recently been declined for life insurance?
*
Yes
No
Based on the information provided. Please visit the
Missouri Farm Bureau Decline Page
for further instructions
Has the client recently been declined for life insurance?
*
Yes
No
Based on the information provided. Please visit the
Farmers Insurance Decline Page
for further instructions
Is your client over the age of 60?
Yes
No
Is your client a medical professional?
Yes
No
Unfortunately based on the information entered we currently do not have a product available at this time to meet your client's needs
Based on the information provided. Please visit the
American Family Page
for further instructions
Requested OCI Split Case Representative
First Available
Yvonne Warren
Chris Basile
Christian Morton
Joe Gordon
Jessica Fletcher
OCI will try to accommodate all requests but there may be times where another agent is assigned if that particular agent is not licensed in the state or certified for the specific line of coverage
Group Name
*
Group Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Number of Employees
*
Would you like your assigned OCI representative to reach out to you prior to contacting the client?
*
Yes *Please disregard auto reply that may say otherwise*
No
Policies written on groups of 3 or less do not result in a split of commission to the referring agent. Speak with your Sales Executive for any additional questions
Additional Notes
CAPTCHA
