Kaiser Oregon Application Agreement

Sign the application agreement

Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application.If there are more than 3 dependents 18 and older signing, please attach a copy of this page with the additional signatures.

• I understand that it may be a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and the cancellation of your policy.

• If I am not purchasing a pediatric dental plan, I attest that I and other dependents on the application have obtained and will maintain a pediatric dental plan certified by the Health Insurance Marketplace.