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Individual Enrolment Form

Opt In

If a student has successfully completed an opt-out but requires re-enrolment into the plan there are 2 opportunities to do so:

1) Upon Program Start Date Anniversary: For students starting in September the anniversary would be the following September prior to the applicable deadline. For eligible students starting in the winter semester, coverage begins January 1st and ends August 31st.

2) Lifestyle Change: There are certain circumstances known as lifestyle changes that allow a student to make changes to their enrolment status within 30 days of the change date. Lifestyle changes include; getting married, meeting the twelve-month co-habitation requirement for common law status, birth/adoption of a child, meeting provincial plan residency requirements and losing their alternate coverage.

Students who lose their comparable coverage may opt back into the Student Benefit Plan(s), if they are within 30 days of losing coverage. If a student has lost their comparable coverage, they must provide documentation of loss by submitting a letter from either the insurance carrier or employer stating the date coverage ends, the carrier name and policy number.

Student Health and Dental 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. The Student will then be contacted by the 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 for the enrolment process to be completed.

Please read and agree to the Terms & Conditions prior to submitting your online Enrolment Form.

Have a safe and healthy year!

Thank you

SAMRU Student Benefits Plan Office
Room Z001, Wyckham House
4825 Mount Royal Gate SW
Calgary, AB T3E 6K6
Phone: 403-440-6267 • Fax: 403-440-8980
Email: mtroyalplan@mystudentplan.ca

Student Information

Gender
Date of Birth
Phone Number
Program Start Date

Please enter the date you lost the coverage


           
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