Reimbursement Verification Form | AmeriLife Marketing Group

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Discounted lead program
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Write 5 MAPD apps for AHIP Reimbursement!

Using the form below, select “AHIP” and provide the required information for verification for $125 reimbursement.

Write MAPD or Med Supp Apps for E& O Reimbursement!

Select “E&O”, then select the appropriate Calsurance option (CalSurance C $305 –OR– CalSurance A $421), the provide the required information for verification. Proof of purchase required.

Write 10 Med Supp/MAPD or FE & Term for Lead Reimbursement!

Using the form below, select “Leads” and provide the required information for verification. Proof of purchase required.

Reimbursement Type. Please select if this is an AHIP, E&O or Leads Reimbursement.

Enter the minimum app thresholds reflected for the reimbursement type selected. Each app may only be used one time and not used for multiple reimbursement requests. No Guaranteed Issue or Under Age applications are accepted. AmeriLife Marketing Group's reimbursements are based off negotiated rates. Any additional cost is solely to the agents. The reimbursement program has time frame, product type and commission level restrictions, please consult with your Marketing representatives for details. AmeriLife Marketing Group reserves the right to change guidelines and rules as needed, without notice.

Reimbursement Type(Required)

AHIP (Requires 5 MAPD Apps)

E&O

Leads (Requires 10 Med Supp or MAPD Apps)

Required Documents

All reimbursements require proof of purchase (AHIP Certification Page, E&O Deck Page, Lead Invoice)

Leads Requirements

AmeriLife Marketing Group offers reimbursement for leads purchased through one of our preferred vendors. Minimum purchase amounts required, please consult with your marketing representative for details.

Preferred vendors:

Real-Time exclusive In-Bound Warm Transfer calls- https://amerilifemarketinggroup.com/leadstar/
Direct Mail - https://www.kramerdirect.com/
Direct Mail - https://leadconcepts.com/contact-us/

E&O Reimbursement

Calsurance $305 (5 Med Supp or MAPD Required)

Calsurance $421 (10) Med Supp or MAPD Required)

Agent Information

Name(Required)

First Last

NPN

Phone(Required)

Email(Required)

Please upload required documents(Required)

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 50 MB.

Required documents: W-9, Voided Check, ACH Form, Proof of Purchase (AHIP Certification Page, E&O Deck Page, Lead Invoice)

Client Information

AHIP Reimbursement: (5) MAPD Apps Required(Required)

Carrier

Agent #

Member Name

Policy #

Date

(10) Med Supp or MAPD Apps Required(Required)

Carrier

Agent #

Member Name

Policy #

Date