MOMCO Refer a Client | Split Case Form

Please fill out the form below to complete your Client Referral.

Important Notice – December 15th Deadline
Due to the approaching December 15th enrollment cutoff, we cannot guarantee that we will be able to contact you before the deadline. As a result, a January 1st start date cannot be guaranteed for requests submitted at this time. If your client needs immediate health coverage, please direct them to HealthCare.gov to complete their enrollment as soon as possible.

Have you completed your individual OCI agreement?*

Yes
No/Unsure

Agent Information

Select Your Agency Affiliation*

If not listed, please select "Other."

Other, Please List Agency Name:*

Referring Agent Name:*

Referring Agent Email*

Client Information

Client Name*

First Last

Client City*

Client State*

Client 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*

Client Birthdate*

Annuity Amount

Annuity 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.

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.

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*

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

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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Refer a Client | Split Case Program

Refer a Client | Split Case Program

Agent Information

Client Information