top of page
CO-OP Marketing Assistance Program 
Chargeback glyph icon, e commerce and ma
Agent Reimbursement Request Form
Total Receipts Attached

By signing, you agree to the terms and conditions of the program and that all marketing must be conducted in compliance with all applicable federal and state laws. Typing your name is equivalent to a handwritten signature.**


 If you are using a vendor other than the approved vendors or are using custom mailing pieces, you must obtain approval from the Keystone Compliance Department prior to use.

Please provide receipts/invoices (showing total spend, vendor name, date invoice paid, and what was purchased), and documentation of production to your local agent manager. Once you submit the Reimbursement Request form, you will receive a response within 24-48 hours from your local agent manager and

Thanks for submitting!

bottom of page