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Oregon Medical Insurance
Pool (OMIP)
Home | Qualifying
Conditions | Eligibility | Provider
Directory | Exclusions | Plan
information and Enrollment Form
Benefits: OMIP Plan
750 | OMIP Plan 1000 | OMIP Plan 1500 | FMIP Plan 500 | FMIP Plan 750
Rates: OMIP Plan
750 | OMIP Plan 1000 | OMIP Plan
1500 | FMIP Plan 500 | FMIP Plan 750
Apply
for coverage from OMIP/FMIP - Download
OMIP/FMIP Enrollment Form
Tips for completing your application:
- Please read everything carefully and answer all
questions honestly. This document becomes part
of your health insurance contract.
- Please complete all sections to the best of your
ability. Please pay special attention to the Health
Condition Section. You need to check every
condition that you have either been diagnosed with
or that you know you have.
- Make sure you include evidence or Oregon Residence
along with the application. There is a list included
with the application...
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage Eligibility for more
information. Please note, if you do not have your
Certificate of Creditable Coverage at the time of
application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by OMIP.
- Payment Options: Do
not send a payment with the application!
- Monthly Bank Draft: Please
complete Authorization section carefully and attach
a voided check. (deposit slip does not work!)
- Monthly billed directly: Simply
check the box , and you are done.
- Quarterly billed directly: Simply
check the box , and you are done.
- Final check list before mailing:
- All sections completed?
- Copy of Insurance Card or Certificate of Credible
Coverage
- Evidence of Oregon Residence
- Signed and Dated
- Voided check if selecting the automated monthly
withdrawal
- Fax all Enrollment Materials to: 541.284.2994,
or
Mail all Enrollment Materials to:
CDA Insurance LLC
PO Box 26540
Eugene, OR 97402
This information is taken from the Oregon Department of
Consumer and Business Services web site. Every reasonable
effort is made to assure the accuracy of the information
provided here. CDA Insurance , LLC is a licensed
and independent agency that can assist consumers in securing
this coverage.
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