Submission of an online 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 Gallivan & Associates;
• an understanding that the information provided is required in order 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; and
• 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/or dental plan(s) coverage. Comparable health and/or 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/or dental plan(s), 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/or dental plan(s). The Student realizes that s/he will not be able to rejoin the plan(s) until the policy anniversary or unless s/he ceases to be covered by the insurance used to opt-out of the student health and/or dental plan(s) and apply within 30 days of losing said coverage. The Student must complete the necessary form, pay any fees associated in rejoining the plan(s) 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, click Opt in button in here 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 EMAIL CONFIRMATION: You will receive a reply email confirmation after you complete and submit the online opt out. Please retain a copy of the email confirmation for your records. The email confirmation is your ONLY proof that you applied to opt-out of the coverage. If you do not receive a confirmation email please contact the Gallivan & Associates before he applicable deadline.

ONLINE OPT-OUT AUDIT: You may be asked to provide documentation of your existing coverage at any time throughout each year of coverage. Documentation must show the name of the insurance company providing coverage and the policy number. Acceptable documentation may be an insurance policy, a photocopy of the policy provision page/schedule of benefits, a benefits booklet, a statement of claim, or a membership card. Without such documentation you will be reinstated to the mandatory benefit plan and assessed the applicable fee.

After the initial Opt-Out Form is processed, the Student is automatically opted-out each consecutive school year ?s/he attends the institution.

FAMILY ENROLMENT FORM: The Student understands that the information provided above is required to provide the same dental and/or 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 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, and who is:
1) under 21 years of age,
2) under 25 years of age and attending a college or university full-time, or
3) physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on The Student for maintenance and support and while eligible under 1) or 2) above.

Your family can only be covered while you are a student on the plan(s).The Student understands that the coverage provided to the plans 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 has previously submitted a Waiver which has been accepted and s/he wishes to withdraw the Waiver.

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/or 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.