Agent Client Referral – OCi Services

Client Referral

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*
- Individual/Family Health (Under age 65)
- Short Term Health
- Dental/Vision
- Medicare
- Life
- Long-Term Care
- Annuity
- Group Medical
- Group Ancillary
- Worksite
- Disability
- Other
Coverage Type*
- Individual/Family Health (Under age 65)
- Short Term Health
- Dental/Vision
- Medicare
- Life
- Long-Term Care
- Annuity
- Disability
- Group Medical
- Group Ancillary
Coverage Type*
- Individual/Family Health (Under age 65)
- Short Term Health
- Dental/Vision
- Medicare
- Life
- Long-Term Care
- Annuity
- Group Medical
- Group Ancillary
- Worksite
- Disability
- Other
Client Birthdate*
MM slash DD slash YYYY
Annuity Amount
Annuity Type
Coverage Type*
- Individual/Family Health (Under age 65)
- Medicare
- Life
- Annuity
- Group Medical
- Group Ancillary
- Worksite
- Disability
- Long Term Care
Coverage Type*
- Individual/Family Health (Under age 65)
- Medicare
- Life
- Annuity
- Group Medical
- Group Ancillary
- Worksite
- Disability
Coverage Type*
- Individual/Family Health (Under age 65)
- Short Term Health
- Medicare
- Disability
Coverage Type*
- Life
- Annuity
- Disability
Coverage Type*
- Group Ancillary
- Medicare
- Disability
Does your client make over $100,000?
- No
- Yes
Coverage Type*
- Individual Health
- Disability
DISABILITY NOTE: Based on the information you have provided, please use the link on your webpage to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your webpage to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your webpage to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your webpage to refer to full details on Disability.
DISABILITY NOTE: Based on the information you have provided, please use the link on your webpage to refer to full details on Disability.
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://staging.ociservices.com/amfam-products/. Thank you!
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
Based on the information provided. Please visit the American Family Page for further instructions
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
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