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Oregon Medical Insurance > Oregon Medical Insurance Pool ( OMIP) > Download Application

OMIP Enrollment Form

Tips for completing your application:

  1. Please read everything carefully and answer all questions honestly. This document becomes part of your health insurance contract.

  2. 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.

  3. Make sure you include evidence or Oregon Residence along with the application. There is a list included with the application...

  4. 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.

  5. 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.

  6. 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

Send all Enrollment Materials to:
CDA Insurance LLC
PO Box 26540
Eugene, OR 97402


























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