Booth - Enrollment 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 Application

Only submit this form if you have previously opted out of the health & dental plan and wish to re-enroll. All new eligible students are automatically enrolled in the Health and Dental plan.

Eligibility Criteria

There are 2 circumstances for re-enrolling in the Student Health and Dental Plan:

1 Academic Enrollment

Students who previously opted out of the benefits and are still eligible for the plan may re-enroll according to the university enrollment:

Fall Enrollment: All eligible students who previously opted out of the plan may submit application if they wish to re-enroll in the Health and Dental Plan before the fall deadline.
Winter Enrollment: Only eligible students who previously opted out and have not attended the Fall term may submit application if they wish to re-enroll in the Health and Dental Plan before the winter deadline.

Winter 2024 deadline is January 26^th, 2024

2 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
boothplan@mystudentplan.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 lifestyle change

If you do not meet the eligibility criteria to be automatically enrolled in the student plan, please do not complete this form. There is no opt-in to the student plan.

Important notes:

All eligible students are automatically enrolled in the Student Health and Dental Plan and do not need to submit an re-enroll form. You will see a health and dental insurance fee on your student account to confirm you are enrolled.
There is a 45-day validation period from the start of the term. During this time, you would have to pay out of pocket for all eligible Health and Dental expenses and keep the receipts. After the enrollment process is complete, you will be able to submit online claims for reimbursement and your Plan Card will be automatically activated for pharmacies and dental offices.
NO EXCEPTIONS will be made if the deadline is missed.
Once you complete the re-enroll 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 request.

Steps to submitting a Re-Enroll Application:

1Student Information

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

2Enrollment 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: boothplan@mystudentplan.ca

Health and Dental Re-Enrollment Form

Please complete all information on the re-enroll 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

Winter Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by January 26^th, 2024

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.

Booth UC Benefits Plan Office

Email: boothplan@mystudentplan.ca
Address: 447 Webb Place
Winnipeg, Manitoba. R3B 2P2

General Inquiries Line

Monday to Friday from 7:00am to 6:00pm CST

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

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