MOFB Split Case Form – Testing

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*

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Referring Agent Phone Number

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Client Information

Client Name*

First Last

Client City*

Client State*

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*

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.

Group Name*

Group Address*

Street Address Address Line 2 City State ZIP Code

Number of Employees*

Additional Notes

Consent*

By checking this box, you are giving OCI permission to reach out to your client on your behalf as your benefits partner. OCI will make the sale as your identified partner, help your client enroll in the best-suited plan, service, and support the policy. Stay informed of your referrals through your OCI online account.

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MOFB Split Case Form – Testing

Captive Agent Client Referral_MOFB

Agent Information

Client Information