USC - PurpleCARE - Opt-In Form

Student Health & Wellness!mystudentplan is a benefits plan for students and can provide coverage for prescription drugs, vision care, dental care, mental health counseling, and more. The plan is designed to supplement provincial health insurance and provide additional access to medical services.

Online Forms

Are you covered by a comparable plan? Do you wish to cover your dependents? Or have you opted out of the plan and wish to be re-enrolled? Eligible Students may submit their online forms.

Health and Dental Re-Enroll or Opt-In Application

Only submit this form if you lost your comparable coverage plan and wish to re-enroll or if you are a full-time equivalent student, or are over 65 years of age and wish to opt-in to the plan.
All new or returning eligible students, including students who previously opted out, are automatically enrolled in the Health and Dental plan.

Eligibility Criteria

There is 1 circumstance for re-enrolling and 1 circumstance for opting into the Student Health and Dental Plan:

1 Loss of Comparable Coverage

Students who previously opted out of the benefits, have lost their comparable insurance coverage, and are still eligible for the plan may re-enroll in the student plan within 30 days of losing that coverage.

Proof of losing coverage must be sent to healthdental@westernusc.ca after completing this form.

Documentation includes a letter from the insurance carrier or the employer stating the student's name, loss of coverage date, the insurance carrier's name & policy number.

Deadline is within 30 days of losing coverage

2 Full-time equivalent students and students over 65 years of age

New or returning students taking a reduced course load due to documented disability, or student over 65 years of age may opt-in to the Plan by completing the online form by the applicable deadline.

Proper documentation to confirm your full-time equivalent must be sent to healthdental@westernusc.ca after completing this form.

Fall 2024 deadline is Monday, September 23^rd, 2024, 11:30 PM

You must only complete this form if you are deemed an eligible student and were not charged the fees.

Important notes:

Students who previously opted out of the benefits are automatically enrolled in the Plan every Fall term.
All international and domestic eligible students are automatically enrolled in the Student Health and Dental Plan and do not need to submit a re-enroll or opt-in form. If you see the Health & Dental Fee included in your tuition, you are covered by the Health and Dental Plan and not need to apply.
The effective date of your coverage is the September 1^st for the fall enrollment and for losing coverage the effective date is the 1^st day of the month when your application is approved.
NO EXCEPTIONS will be made if the deadline is missed.
Once you complete the Re-Enroll or Opt-In form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting an Re-Enroll or Opt-In request.

Steps to Submitting a Re-Enroll or Opt-In Application:

1Student Information

Complete this section below providing true and correct information. Click NEXT.

2Enrolment Circumstances

Scroll down and check Health Plan/Dental Plan/Qualify. You can choose Health or Dental or both plans. Select your status and Click NEXT.

3Read and Agree to the Terms and Conditions

Click on the checkbox to indicate that you agree to the Terms and Conditions agreement. Click SUBMIT to finish your application.

4Confirmation email

Check your email and verify if you have received the confirmation email. If you do not receive this email, you must resubmit the form.

5Application status

You will receive an email with the status of your application.

6Pay the fees

If your application is approved, the fees will be included in the student account.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: healthdental@westernusc.ca

Health and Dental Re-Enroll or Opt-In Form

Please complete all information on the re-enroll/Opt-In form and we will process your application as soon as we can.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Sex

F

M

U

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Fall Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by September 23^rd, 2024 at 11:30 PM

Plan Card Generator
Generate your Plan Card and use it where direct billing to Canada Life is available.

Prescription Search Tool
Find out if your prescription drugs are covered by the student plan.

Plan Claims
Learn more about submitting online or manual claims to Canada Life to get your refund.

USC Benefits Plan Office

Email: healthdental@westernusc.ca
Address: University Community Centre
Room #320
1151 Richmond St
London, Ontario N6A 2K5

General Inquiries Line

Monday to Friday from 8:00am to 7:00pm EST

Phone: 1-877-746-5566 Ext. 7249

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Online Forms

Health and Dental Re-Enroll or Opt-In Application

Eligibility Criteria

Steps to Submitting a Re-Enroll or Opt-In Application:

Health and Dental Re-Enroll or Opt-In Form

The fall 2023 re-enroll or opt-in deadline is closed.

Health and Dental Re-Enroll or Opt-In Form

Student Information

USC Benefits Plan Office

General Inquiries Line

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