Co-op Request Name(Required) First Last Are you an Agency Principal(Required) Yes No Agency Name Email(Required) Enter Email Confirm Email PhoneI am requesting Co-op support for the following:Select all that apply AEP OEP SEP Carrier DetailsCo-op support requested for:Select all that apply Aetna Anthem Banner Cigna Devoted Humana UnitedHealthcare Wellcare Other AetnaAetna Production ExpectationsAetna Dollars RequestedAnthemAnthem Production ExpectationsAnthem Dollars RequestedBannerBanner Production ExpectationsBanner Dollars RequestedCignaCigna Production ExpectationsCigna Dollars RequestedDevotedDevoted Production ExpectationsDevoted Dollars RequestedHumanaHumana Production ExpectationsHumana Dollars RequestedUnitedHealthcareUHC Production ExpectationsUHC Dollars RequestedWellcareWellcare Production ExpectationsWellcare Dollars RequestedOtherOther Production ExpectationsOther Dollars RequestedTotal Dollars Requested(Automatically subtotaled)Campaign DetailsMarketing Activities or Tactics EmployedDownline Agents/entities supportedCommitment to send any/all Campaign invoices/receipts(Required) I hereby commit to submit all invoices and receipts of marketing costs for this marketing program.
