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Individual Enrolment Form

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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

Date of Birth
Phone Number
Program Start Date

Please enter the date you lost the coverage

please use format 'mm/dd/yyyy' if you use Internet Explorer

Service Members

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