One week left to submit your enrollment form for coverage starting 1/1/14

Sample

Plan Selection and Enrollment Form

Please use this form to tell us which health insurance plan you have chosen for each shopping group.

You can choose one plan for each shopping group using this form.

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Enrollment information

Please enter the values below exactly as they appear in your enrollment packet.

Effective Date*                             January 1, 2014                             February 1, 2014                             March 1, 2014                         

Case number*ex: 1-23456789

Shopping group number*ex: 1-12341234

Medical plan name*

Medical plan ID number*ex: 12345OR1234567-00

Dental plan name

Dental plan ID numberex: 12345OR1234567

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Monthly Premium Tax Credit

How much would you like to apply to your premium?

Maximum amount shown on your enrollment form

Other amount:(not to exceed the maximum shown
on your enrollment form)

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Certified Insurance Agent or Community Partner Information (if applicable)

Agent/Community Partner Name

Agent/Partner #

Organization Name

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Read and Sign

A person from each shopping group who is enrolling coverage must sign this enrollment form. Alternatively, a previously chosen authorized representative may sign.

By signing the form, you agree that you are authorized to complete and submit this application on behalf of yourself and all enrolling individuals, and if applicable, the terms for Qualified Health Plan enrollment and of the Advanced Payment of Premium Tax Credit (APTC). View full terms and conditions.

Signature*

https://www.coveroregon.com/enrollment