Clover Health Event Registration Form
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Contract Number *
Contract Year *
Presentation Language *
Type of Event *
Event Name *
Event Date *
MM
/
DD
/
YYYY
Event Time *
Time
:
Brokerage Firm/Agency *
Facility Type *
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 *
Required
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