Skip to content
Call Us: 402.330.8700
Home
Who We Are
Our Story
Our Staff
Join Our Team
What We Do
Individual Health
Group Benefits
Split Cases/Client Referral
Medicare
Life, Disability, LTC, Annuities
Resources
Department/Product Resources
Agent Bonus Programs
Webinars
Compensation Disclosure
Events
Partner With Us
Login
Search for:
Amfam Split Case Form – Testing
Home
Amfam Split Case Form – Testing
Captive Agent Client Referral_AmericanFamily
Please fill out the form below to complete your Client Referral.
Have you completed your individual OCI agreement?
*
Yes
No/Unsure
Agent Information
Referring Agent Name:
*
Referring Agent Email
*
Referring Agent Phone Number
*
Are you the principal of the agency
*
Yes
No
Name of Agency
Agency Name:
Client Information
Client Name
*
First
Last
Client City
*
Client State
*
Alabama
Arizona
Arkansas
Colorado
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Client Zip Code
*
ZIP Code
Client Phone Number:
*
Client Email
*
Email Requirement: 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. If your client does not have email or a valid email is not provided, we will not be able to assist your client due to compliance reasons of needing electronic signatures for consent and policy completion.
Coverage Type
*
Group Ancillary
Medicare
Prescription Drug/Part D/PDP Only
Disability
Does your client make over $100,000?
*
No
Yes
Due to a number of insurance carriers no longer working with agents to solicit their products we are unable to help your client secure Prescription Drug coverage. If they would like to review their options and enroll please forward this self service link to them
click here
DISABILITY NOTE: Based on the information you have provided, please use the link on your
webpage
to refer to full details on Disability.
OTHER PRODUCTS:
For all other products to refer go to American Family's web page:
https://www.ociservices.com/amfam-products/
. Thank you!
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
Additional Notes
CAPTCHA
Page load link