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This Personal Information Form is to be used by students who are automatically enrolled in the Student Health and Dental Plan(s), and wish to activate the coverage for such plans. This form should be submitted as soon as possible. DO NOT WAIT UNTIL YOU NEED TO ACCESS THE COVERAGE TO SUBMIT THIS FORM , or your claim will be delayed.

This form is required for you to provide the personal information necessary to activate insurance coverage. You must complete and submit this form to authorize the use of your information for the purpose of providing coverage under the plans. The assessment of the fees establishes your coverage, but activation cannot occur until the eligible student has completed and submitted this form.

Please read and agree to the Terms & Conditions prior to submitting your Personal Information Form.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Gender

MaleFemale

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

For your convenience, after this form has been submitted, the information is on file each subsequent consecutive school year that you are assessed the plan fees. If there is a semester where you are not eligible, then you will have to resubmit this form during the next semester of eligibility.

Should you have any questions regarding the Personal Information Form please contact the SAMRU Student Benefits Plan Ofice prior to submitting this form.

Enrolment is not guaranteed by submitting this form;The Student must be eligible for the program.

I Agree to the Terms & Conditions

Opt In

This form is only for students who have previously opted out and are looking to re-enrol in the plans. 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 Policy Anniversary: For students starting in September the anniversary would be the following September prior to the applicable deadline. For students starting in January the anniversary would be the following January prior to the applicable deadline.

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. Lifestyle changes include; getting married or 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 plan(s), provided that they are within 30 days of losing coverage. If a student has lost their comparable coverage they must show documentation of loss by submitting a letter from either the insurance carrier or employer.

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

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

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 SAMRU Student 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 in order for the family add on process to be completed.

Please Note: January Family Add On fees are for 8 months of coverage, expiring August 31. All plans are reset on September 1, and family add ons must be re-purchased before the applicable deadline.

Full-time students that miss the Fall deadline are NOT eligible to add family members in the Winter semester but are eligible to add family members in the following Fall semester. The Winter semester family add on is only for brand new students starting in January.

Please read and agree to the Terms & Conditions prior to submitting your online Family Add On form.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

The Winter semester opt-out is only for brand new students starting in January.

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 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.

*Please note: Full-time students that miss the Fall deadline are NOT eligible to opt-out in the Winter semester, but are eligible to opt-out in the following Fall semester. The Winter semester opt-out is only for brand new students starting in January. Audits are performed each semester to uphold the integrity of the opt-out process.

Approval of your opt-out will result in the plan fee being refunded. Once your opt-out has been accepted, it will remain in force as long as you remain an eligible student.

If you are unsure about whether or not you are eligible for the Student Health and Dental plan, please contact the SAMRU Student Benefit Plan Office prior to any applicable deadlines.

Please read and agree to the Terms & Conditions prior to submitting your online opt-out.