MOMCO Refer a Client | Split Case Form

As the deadline for Individual ACA comes to an end on Dec 15th we cannot guarantee we will be able to connect with your client before the deadline to secure a January 1st effective date. If your client needs immediate help please have them contact 1-800-318-2596 or visit healthcare.gov

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 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*

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*

Client Birthdate*

Annuity Amount

Annuity Type

Coverage Type*

Individual/Family Health (Under age 65)
Medicare
Prescription Drug/Part D/PDP Only
Life
Annuity
Group Medical
Group Ancillary
Worksite
Disability

Coverage Type*

Individual/Family Health (Under age 65)
Short Term Health
Medicare
Prescription Drug/Part D/PDP Only
Disability

Coverage Type*

Life
Annuity
Disability

Coverage Type*

Group Ancillary
Medicare
Prescription Drug/Part D/PDP Only
Disability

Does your client make over $100,000?*

No
Yes

Coverage Type*

Individual Health
Disability

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.

OTHER PRODUCTS: For all other products to refer go to American Family's web page: https://www.ociservices.com/amfam-products/. Thank you!