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OmniFlex 1st App Claim Form

Congratulations! You’ve sold your first OmniFlex™ Short-Term Care insurance application!

To claim your $200 CASH BONUS reward, complete the form below.

Questions? Call our Marketing Team at 800-842-7799.

Name(Required)

First Last

Email(Required)

Phone(Required)

State(Required)

1st Application Completion Date(Required)

Policy Number(Required)

Client Name?(Required)

Please upload your completed W-9 Form (make sure you sign it!)(Required)

Accepted file types: pdf, Max. file size: 128 MB.

Please upload your completed Direct Deposit form(Required)

Accepted file types: pdf, Max. file size: 128 MB.

Name

This field is for validation purposes and should be left unchanged.