Menumenu button

Forms

Please select a form

Due to the high volume of online applications, it may take a few minutes for the following pages to load after clicking the "Next" or "Submit" buttons. Thank you for your patience.



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 through myKwantlen (online services) 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.

The opt-out process must be completed each year that you are assessed the Health and Dental Plan fee.

If your financial situation makes it difficult to pay fees, KPU and the KSA have programs that can assist. There is assistance through KPU Student Awards and Financial Assistance, including emergency bursaries, emergency loans and fee deferral.

The KSA also has a Health & Dental  Hardship Bursary, please see the policy for more details - download the application HERE
Please visit http://www.kwantlen.ca/webreg to complete your online opt out.

The myBenefits Card is an important piece of identification that will ease access to your benefits. All eligible students must complete the myBenefits Card Registration Form. This multi-purpose card provides your policy information for submission of claims at both the Pharmacy and the Dental Office.

To obtain your myBenefits Card you must first register for BC Fair Pharmacare. Once your registration is completed simply complete the myBenefits Card Registration Form.

Please note: if you are not a permanent resident of BC you must still fill out the registration form providing your home province or country in place of the Fair Pharmacare registration number.

Downloading the myBenefits Card does not confirm eligibility or benefits coverage. Please contact the KSA Benefit Plan Office to confirm your enrolment in the plan.

 



Student Information

Gender
Date of Birth
Phone Number
Program Start Date
 
  • British Columbian Students - Please list your BC Fair PharmaCare Number
  • Out of Province Students - Please list your home province
  • International Students - Please list your country of residence
Please indicate how you would like to access your benefits card


Enrolment in the Student Health and Dental plan not guaranteed by submitting this form; The Student must be eligible for the program.

Should you have any questions regarding the enrolment process please contact the KSA Student Benefit Plan Office prior to submitting this form.

I understand the information provided above is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the institution, the student organization, the Student Service Co-ordinator, Gallivan & Associates, BCE Emergis Assure Health Division, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that the Student Service Coordinator may need to notify the institution to find out whether or not I have paid for the plan.

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 Office of the Registrar, 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 enrolment process to be completed.  The deadline for completing this form is on the your plan anniversary or 30 days after losing comparable coverage.  

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

If your financial situation makes it difficult to pay fees, KPU and the KSA have programs that can assist. There is assistance through KPU Student Awards and Financial Assistance, including emergency bursaries, emergency loans and fee deferral.

The KSA also has a Health & Dental  Hardship Bursary, please see the policy for more details - download the application HERE


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 Office of the Registrar, 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.
IMPORTANT: These fees are in addition to the student health and dental fee.

2018 - 2019 Family Add-On Fees:
Health (one or more dependent) $120.00
Dental (one dependent) $160.00
Dental (two or more dependents) $240.00
Health & Dental (two or more dependents) $360.00

Please note: Your optional family add-on is not automatically renewed. In order for your family add-on to continue, you must purchase the coverage each benefit year before the applicable deadline. FAMILY ADD-ON FEES ARE NON-REFUNDABLE.

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

Service Members


Find a Practitioner