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Declined Life Cases
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Refer a Client
Declined Life Cases
Product Resources
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Refer a Client | Split Case Program

Refer a Client | Split Case Program

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*
Please select N/A if agency is not listed
Are you the principal of the agency*
- Yes
- No
Name of Agency
Agency Name:
Client Name*
First Last
Client City*
Client State*
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
- Disability (If looking for Short-Term Disability, please note maternity leave is not covered.)
- Annuity
- Group Medical
- Group Ancillary
- Worksite
- Other
Client Birthdate*
MM slash DD slash YYYY
Annuity Amount
Annuity Type
Coverage Type*
- Individual/Family Health (Under age 65)
- Short Term Health
- Medicare
Coverage Type*
- Life
- Long-Term Care
- Disability (If looking for Short-Term Disability, please note maternity leave is not covered.)
- Annuity
- Group Ancillary
Coverage Type*
- Long-Term Care
- Disability (If looking for Short-Term Disability, please note maternity leave is not covered.)
- Group Ancillary
- Medicare
Coverage Type*
- Individual Health
- Long-Term Care
- Disability (If looking for Short-Term Disability, please note maternity leave is not covered.)
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
Requested OCI Split Case Representative
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 State ZIP Code
Number of Employees*
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
We do not have access to rates or plans for 2023 until the Open Enrollment period begins on November 1st. If this is for a January 1st or later start date we kindly ask you to resubmit the referral at that time.
Additional Notes
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Questions? Please contact us at 402.330.8700 .

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