Application Form FILLABLE.pdf
PDF 157 KB Posted
- Solicitation number
- S-44300-00001160
- Issued by
- Oregon
About this file
This document is an Application Form for a Request for Application (RFA) 5304 issued by the Oregon Health Authority (OHA) for volunteer enrollment assistance and system navigation services. Applicants must meet the minimum qualifications described in the RFA and submit the completed Application Form through OregonBuys to be considered for a contract. The Application Form collects information about the applicant organization, including the region(s) or area(s) of the state the organization intends to serve, the type of organization, and any potential conflicts of interest. Applicants must also confirm they meet the commercial general liability and automobile insurance requirements or agree to meet them prior to contract execution.
The related state and local contract opportunity is for the OHA to request applications from qualified individuals or organizations to provide volunteer enrollment assistance and system navigation to Oregon families and individuals applying for health coverage through OHA or HealthCare.gov.
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Other files
| File | Type | Posted |
|---|---|---|
| RFA 5304 updated Feb 15 2022.pdf | ||
| Engineered Monitoring Solutions Sole Source.pdf |
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Text version
Attachment 1 – APPLICATION FORM
Applicants must meet the Minimum Qualifications, as described in Request for Application (RFA) 5304.
Applicants must submit this completed Application Form through OregonBuys to be considered for a Contract/Agreement.
Volunteer Organization Information Organization Name:
Mailing Address:
City: State: County: Zip Code:
Physical Address:
Phone:
Tax ID (EIN):
What region(s) or area(s) of the state does your organization intend to serve?
Please be as specific as possible.
Type of Organization Advocacy Group Other service organization Governmental Food bank Faith-based organization Education Service District (ESD) Tribal organization Financial service organization Head Start Minority organization Fraternal/service organization School Medical care provider Day Care Provider (licensed or registered) Other Governmental:
Insurance Organization
Conflict of Interest Applicants must not be an individual or entity that has a conflict of interest and may not be an individual or entity that has the appearance of a conflict of interest. If a conflict of interest exists, or may exist, you will be contacted to provide an explanation. Insurance Organizations shall disclose all relationships with insurers, their subsidiaries or other potential conflicts of interest.
Conflict of interest exists for:
Insurers and their subsidiaries Issuers of Stop Loss Insurance Members of, or individuals who lobby on behalf of, the insurance industry Individuals or entities receiving direct or indirect consideration from insurers in connection with enrollment of individuals in a health insurance plan
Insurance Commercial General Liability Insurance Yes, Applicant currently meets the CGL insurance requirement.
Do not currently meet CGL insurance requirements, and will meet requirement prior to Contract execution.
Automobile Insurance Requirements Yes, Applicant currently meets the Auto insurance requirement, or will meet requirement prior to Contract execution.
No, do not meet Auto insurance requirement and will not travel to assist applicants and consumers with enrollment. Applicant assumes full responsibility should OHA agree to waive this requirement.
Organization’s Contract Administrator
Name and Title:
Phone:
Email:
Applicant, by signing this Application, certifies that they have read, understands and agrees to comply with RFA 5304.
Signature:
| Organization Name: |
| Mailing Address: |
| Physical Address: |
| Phone: |
| Tax ID EIN: |
| What regions or areas of the state does your organization intend to serve Please be as specific as possible: |
| Advocacy Group: Off |
| undefined: Off |
| undefined_2: Off |
| undefined_3: Off |
| undefined_4: Off |
| Education Service District ESD: Off |
| Tribal organization: Off |
| Financial service organization: Off |
| undefined_5: Off |
| Minority organization: Off |
| Fraternalservice organization: Off |
| undefined_6: Off |
| Medical care provider: Off |
| Day Care Provider licensed or registered: Off |
| undefined_7: Off |
| undefined_8: Off |
| undefined_9: Off |
| undefined_10: Off |
| Individuals or entities receiving direct or indirect: Off |
| undefined_11: Off |
| Yes Applicant currently meets the CGL insurance requirement: Off |
| Do not currently meet CGL insurance requirements and will meet requirement prior to Contract execution: Off |
| Yes Applicant currently meets the Auto insurance requirement or will meet requirement prior to Contract: Off |
| No do not meet Auto insurance requirement and will not travel to assist applicants and consumers with: Off |
| Name and Title: |
| Phone_2: |
| Email: |
| Text2: |
| Text3: |
| Text4: |
| Text5: |
| Clear Form: |
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