PacificSource Oregon Application Agreement

Certify, Authorize, and Sign

Be sure to sign and date the enrollment form on this and the following page. Your spouse or domestic partner’s signature is also required (if applicable) as is the signature of any child over the age of 18. You may request a free paper copy of your application and/or enrollment information by contacting our Commercial Enrollment and Billing Department via email at individual@pacificsource.com or by phone at (866) 695-8684.

Certification of Completeness and Correctness I affirm that the answers given in this enrollment form are complete and correct. I am providing these answers as part of the enrollment form procedure required by PacificSource to enroll in its insurance coverage. I understand that if this enrollment form contains any intentional misrepresentation of material fact or fraud, PacificSource may modify or cancel the contract, and/or take any other legal action available by law. I will promptly inform PacificSource in writing if anything happens before my coverage takes effect that makes the information I have provided on this enrollment form incomplete or incorrect. I understand and agree that no coverage will be in force until accepted by PacificSource. If accepted, coverage will be in force as of the effective date determined by PacificSource. A representative of PacificSource may contact me to clarify answers on this enrollment form. Representations made by the enrollee are deemed to be representations made on behalf of each person covered under this policy. However, changes to the enrollment form will not be effective until approved in writing by the enrollee. An enrollment form received by PacificSource requiring alterations will be modified by amendment and sent to the enrollee for signature. As the enrollee, I understand I have the right to inspect the information in my file.

I (We) have reviewed and understand the authorization above.