Dependent Application 2011 - coverageforall-2026

1. Click ‘Get Form’ to open the Dependent Application 2011 in the editor.
2. Begin by filling out the Applicant/Dependent Information section. Enter the policyholder’s name, birthdate, contact numbers, and email address. Ensure all fields are completed in ink.
3. Provide your Oregon residence address and mailing address if different. List all dependents you wish to insure, including their names, genders, birthdates, and relationships.
4. In the Proof of Eligibility section, confirm your residency status by initialing the statement provided. Attach a copy of an acceptable document that verifies your residency.
5. Complete the Statistical & Eligibility Information section by answering questions about previous insurance coverage and ethnic/racial heritage.
6. Review and initial the Affirmation, Understanding & Disclosure Authorization section to confirm your understanding of OMIP policies.
7. Finally, complete the Premium Payment section without sending payment at this stage. Indicate your preferred payment method.

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