AHIP REIMBURSEMENT

Contracted Agents Only

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AHIP REIMBURSEMENT FORM

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Agent Full Name: *

Agency Name:

Resident State: *

E-mail address: *

Telephone/fax: *

NPN: *

Are You Full-Time In The Insurance Business?

The date completed training: *

Insurance Carrier You Took The Exam Through? *

Is This Your First Year Taken The Exam? *

Note: Fields marked with * are required

* Please note, that any outstanding marketing balance will be deducted first, before AHIP reimbursement.

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