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Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
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Oregon Health Insurance Information Request

We would like to hear from you. Please provide us with some basic information and what you are interested in and we will furnish you with your information, or you may call us at (541) 434-9613 or (800) 884-2343.  

Please note that items in Bold Blue are required to submit the form.

If you are looking for information about Medicare Supplements, Medicare Advantage plans or Medicare Part D coverage, please use this form.
Census Information -(More detail for more accurate quote)
Name
Date of Birth
Gender
Detail
Male
Female		 Height: ft. in.
Weight: lbs.
Smoker? Yes No
Male
Female		 Height: ft. in.
Weight: lbs.
Smoker? Yes No
Street Address:
City:
County:
State:
Zip:
Daytime Contact Phone:   (Used for any questions about your request.)
E-mail:
Please call me right away to answer my questions.
Please give me more information about:
Individual Health HSA Plans
Short Term Medical Dental
Please list all individuals (you, your spouse and dependents) you wish to cover.
Children
Name
Date of Birth
Gender
Detail
Male
Female		 Height: ft. in.
Weight: lbs.
Male
Female		 Height: ft. in.
Weight: lbs.
Male
Female		 Height: ft. in.
Weight: lbs.
Male
Female		 Height: ft. in.
Weight: lbs.
Male
Female		 Height: ft. in.
Weight: lbs.
Male
Female		 Height: ft. in.
Weight: lbs.
If you have more than 6 children, simply submit this form additional times.  You will only need to enter your name on the other submissions.

Please list any relevant health conditions.

Please, type the verification numbers:

Oregon Health, Dental and Life Insurance




 

 

 
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