Submission of a form indicates:
- an understanding that it is solely the responsibility of the student whose name and identification number (The Student) is on the form to ensure that the form has been received by The DSU Office;
- an understanding that the information provided is required in order to fulfill the purpose of the form;
- authorization and consent to the use, release and exchange of said information between the educational institution, the student organization, the plan broker, third party service providers and the insurance company(s) to be used solely in connection with the administration of the Student Benefits Plan;
- confirmation that all the information provided is accurate;
- that additional terms as indicated below by type of form also apply.
Falsification of any information provided by The Student is considered to be a serious form of fraud.
OPT-OUT FORM: The Student wishes to decline the student health and dental plan coverage. Comparable health and dental coverage are presently provided for the student under another insurance plan. The Student understands that s/he would have been able to claim under his/her existing insurance as well as under the student health and dental plan, thereby increasing coverage.
The Student acknowledges that as a result of the opt-out, s/he forfeits all rights to coverage otherwise available to him/her under the student health and dental plan. The Student realizes that s/he will not be able to rejoin the plan until the policy anniversary or unless s/he ceases to be covered by the insurance used to opt-out of the student health and dental plan and apply within 30 days of losing said coverage. The Student must complete the necessary form, pay any fees associated in rejoining the plan and provide the necessary proof of loss of insurance in order to reinstate coverage.
OPT-OUT DEADLINE: The opt-out deadline dates are established by the Institution or Student Organization. You will not be able to opt-out of coverage at any other point during the school year. For example, if your program starts in September, you must opt-out prior to the end of the Fall deadline. The same rule applies for opting in (unless you lose your comparable coverage, see below for loss of coverage information). NO EXCEPTIONS will be made if the deadline is missed. It is The Student's responsibility to pay the plan fees, should they miss the applicable opt out deadline.
Opt-out requests
do not carry forward. Should you wish to opt-out of the student plan in subsequent years, you will need to complete the opt-out process again before the established deadline for your semester period of enrolment.
FAMILY ENROLMENT FORM: The Student understands that the information provided above is required to provide the same dental and extended health benefits received as a student to spouse and/or dependent(s). The Student has the authority to provide such information and authorizes the use of the information provided where it is required in the administration of the insurance benefits. The Student understands that in order to receive coverage for an eligible spouse or dependent the appropriate fee must be paid. The Student agrees to pay the appropriate fees for the coverage requested prior to the applicable deadline.
The Student confirms that the individual(s) for whom coverage is being requested qualify based on the eligible definitions of spouse or dependent.
Definition of Spouse: Spouse means the person who is a resident of Canada, and who is married to The Student, or a person of either sex who has continuously co-habitated (common law) with The Student for a period of at least 12 months and who is publicly represented as The Student's wife or husband.
Definition of Dependent(s): Dependent means an unmarried child who is a resident of Canada, and entirely dependent on The Student for maintenance and support, Dependent children may be covered by a dependent/family
optional coverage until the age of twenty-one (21).
Your family can only be covered while you are a student on the plan.The Student understands that the coverage provided to their family will need to be renewed each Benefit Year.
FAMILY ADD-ON FEES ARE NON-REFUNDABLE.
Family Enrolment is not guaranteed by submitting this form; the applicant must be eligible for the program and the appropriate fees must be paid.
INDIVIDUAL ENROLMENT FORM: The individual enrolment form can be used in circumstances as indicated below.
1) In circumstances where The Student's status makes him/her eligible for the program but s/he has been excluded from automatic inclusion by the institution.
2) In circumstances where The Student who opted-out loses coverage and opts-in to the Student Plan within 30 days.
The Student understands that in order to receive coverage the appropriate fee must be paid. The Student agrees to pay the appropriate fees for the coverage requested prior to the applicable deadline.
The Student understands that information provided above is required to provide the dental and extended health benefits. The Student authorizes the use of the information provided where it is required in the administration of the insurance benefits.
Please note: your status may require that you complete this process each enrolment period.
ENROLMENT FEES ARE NON-REFUNDABLE.
Individual Enrolment is not guaranteed by submitting this form; the applicant must be eligible for the program.
myBENEFITS CARD REGISTRATION FORM: I understand the information provided above is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the College, the Students' Union and Gallivan & Associates, Telus Health, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that The DSU Office may need to notify the institution to find out whether or not I have paid for the plan
. Registering for the myBenefits Card does not confirm eligibility or benefits coverage. Please contact the DSU to confirm your enrolment in the plan.