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Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994
Oregon Medical Insurance > Ask Questions or Request a Quote >

For information and confidential quotes, fill out and submit to get us working for you. We will respond quickly.


Census Information - (More detail for more accurate quote)
The fields in dark blue are required for form submission.
Street Address:
City:
County:
State:
Zip:
Daytime Contact Phone:
  (Used for any questions about your request.)
E-mail:
I live in Oregon / Washington
I'm moving to Oregon / Washington
If not in these two States, find plans for your state.
Please call me right away to answer my questions.
Individual Health
Disability
HSA
Short Term Medical
Medicare Supplement
Dental/Rx
Life
Long Term Care
Alternative Care

Please list all individuals (you, your spouse and dependents) you wish to cover.
Name
Date of Birth

Gender

Detail
Male
Female
 Height: ft. in.
Weight: lbs.
Smoker? Yes No
Name
Date of Birth

Gender

Detail
Male
Female
 Height: ft. in.
Weight: lbs.
Smoker? Yes No
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. If none are listed, your quote will be based on Preferred Rates unless Height/Weight ratios or smoking dictate otherwise:

Please, type the verification numbers:

Oregon Health, Dental, Disability and Life Insurance

Or call us at our office: 1-800-884-2343

 

 

 
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