2025 AEP Co-op Reimbursement Request form

Request AEP 2025 Co-Op Reimbursement

Agent/Agency Name(Required)

Phone Number(Required)

Email(Required)

Carrier Campaign:

Estimated App Counts per Carrier

Amount to Co-Op per Carrier

aetna-checked

Aetna

aetna-app-estimate

aetna-co-op-amount

bcbs-checked

BCBS TN

bcbs-app-estimate

bcbs-co-op-amount

cigna-checked

Cigna

cigna-app-estimate

cigna-co-op-amount

elevance-checked

Elevance

elevance-app-estimate

elevance-co-op-amount

humana-checked

Humana

humana-app-estimate

humana-co-op-amount

Markets Targeted (Cities/Counties, States)(Required)

How Will These Funds Be Utilized to Create Membership?(Required)

Agents in Hierarchy that will be receiving or being supported by co-op from this request(Required)

CAPTCHA