Clover Health Event Registration Form

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Contract Number *

Contract Year *

Presentation Language *

English

Spanish

Cantonese

Mandarin

Korean

Armenian

Other:

Type of Event *

Event Name *

Event Date *

YYYY

Event Time *

Time

Brokerage Firm/Agency *

Facility Type *

Online Plattform( ZOOM, Facebook, google Video, internet, webinar etc)

Retail Store/Store Front/Grocery Store

Health Fair/State Far/County Fair

Doctor's Office

Health Plan/ Insurance Business Office or Facility

Hospital Clinic/Conference Room/ Business Office

Hotel/Motel

Library

Mall Kiosk

Senior Apartments/ Senior Centers/ Assisted Living

Recreational/Community Center

Nursing Home/Skilled Nursing Facility/Rehab Facility

Community Based or Restaurant (Member Meeting)

Other:

Agent National Producer Number ( NPN) *

Agent Full Name *

Agent contact/Event contact number *

Agent email address for confirmation *

Venue Name ( or name of facility, Group ) *

Venue Phone/or contact in site *

Venue address *

Venue City *

Venue State *

Venue Zip Code *

Event Contact name (if different from Agent, social worker, Store manager) *

Additional Notes/Comments:

PLEASE NOTE: Upon submission of your events, your event will be reviewed and You will be contacted within 72hrs.

PLEASE REVIEW THE LINK BELOW BEFORE SUBMITTING: By checking the box below I acknowledge the 2023 Agents Enrollment Marketing Event Guidelines located here: https://cdn.cloverhealth.com/filer_public/ad/75/ad759fad-8fee-4653-9605-fe1357e93a8c/20bx009_marketing_and_sales_guidelines_v1.pdf *

I have read and understand the Agent Enrollment Marketing Event Guideline

Required

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