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The deadline has passed for September 2018 starts. Please stay tuned for the January 2019 Opt in, Opt Out or Family Add On form.
This Personal Information Form is to be used by students who are automatically enrolled in the Student Health and Dental Plan(s), and wish to activate the coverage for such plans. This form should be submitted as soon as possible. DO NOT WAIT UNTIL YOU NEED TO ACCESS THE COVERAGE TO SUBMIT THIS FORM , or your claim will be delayed.

This form is required for you to provide the personal information necessary to activate insurance coverage. You must complete and submit this form to authorize the use of your information for the purpose of providing coverage under the plans. The assessment of the fees establishes your coverage, but activation cannot occur until the eligible student has completed and submitted this form.

Please read and agree to the Terms & Conditions prior to submitting your Personal Information Form.


Student Information

Date of Birth
Gender
Phone Number
Program Start Date
For your convenience, after this form has been submitted, the information is on file each subsequent consecutive school year that you are assessed the plan fees. If there is a semester where you are not eligible, then you will have to resubmit this form during the next semester of eligibility.

Should you have any questions regarding the Personal Information Form please contact the SAMRU Student Benefits Plan Ofice prior to submitting this form.

Enrolment is not guaranteed by submitting this form;The Student must be eligible for the program.




Opt In


Student Benefits Plan coverage is provided to eligible students automatically, except in certain circumstances where a student’s enrolment status excludes them from automatic inclusion by the institution or due to a previous waiver on file. To enroll in the Student Health and/or Dental plan(s), complete the sections below and submit this form. You will then be contacted by the SAMRU Student Benefit Plan Office, via an email notification, of any required supporting documents and/or fees. All supporting document(s) and/or fees must be received by the applicable deadline in order for the enrolment process to be completed.

Please read and agree to the Terms & Conditions prior to submitting your online enrolment form.

Student Information

Gender
Date of Birth
Phone Number
Program Start Date

Family Add On


Coverage provided through the Student Health and Dental plan can be extended to a spouse and/or dependent(s). To add eligible dependent(s) complete the sections below and submit this form. You will then be contacted by the SAMRU Student Benefit Plan Office, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the family add on process to be completed.

Please Note: January Family Add On fees are for 8 months of coverage, expiring August 31.  All plans are reset on September 1, and family add ons must be re-purchased before the applicable deadline.   

Full-time students that miss the Fall deadline are NOT eligible to add family members in the Winter semester but are eligible to add family members in the following Fall semester. The Winter semester family add on is only for brand new students starting in January.

Please read and agree to the Terms & Conditions prior to submitting your online Family Add On form.

Student Information

Gender
Date of Birth
Phone Number
Program Start Date

PLEASE NOTE: THIS IS THE OPT-OUT FORM FOR MOUNT ROYAL STUDENTS ONLY! IF YOU DO NOT ATTEND MOUNT ROYAL PLEASE CLICK HERE TO SELECT YOUR SCHOOL.    

Already have coverage?

Coordinating multiple plans: If you are an eligible student and have comparable coverage you may wish to coordinate your plans. Benefits under the two plans can be coordinated to increase your coverage up to 100% of the actual expense(s) incurred. For example, following payment under this plan you can submit outstanding balances to the other plan for consideration. Find out more about coordination of benefits.

Opting Out of coverage: If you are an eligible student and have comparable health and/or dental coverage you may apply to opt-out of the plan(s). Each student is given one opportunity to opt-out of the health and/or dental plan(s) each year. All opt-out forms must be completed online or through the Student Benefits Plan Office and must be received by the applicable deadline. You will not be able to opt-out of coverage at any other point during the school year. 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.

*Please note: Full-time students that miss the Fall deadline are NOT eligible to opt-out in the Winter semester, but are eligible to opt-out in the following Fall semester. The Winter semester opt-out is only for brand new students starting in January. Audits are performed each semester to uphold the integrity of the opt-out process.
Approval of your opt-out will result in the plan fee being refunded. Once your opt-out has been accepted, it will remain in force as long as you remain an eligible student.

If you are unsure about whether or not you are eligible for the Student Health and Dental plan, please contact the SAMRU Student Benefit Plan Office prior to any applicable deadlines.

Please read and agree to the Terms & Conditions prior to submitting your online opt-out.


Student Information

Date of Birth
Phone Number
Program Start Date

Service Members


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