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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

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 Program Start Date Anniversary: For students starting in September the anniversary would be the following September prior to the applicable deadline. For eligible students starting in the winter semester, coverage begins January 1st and ends August 31st.

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 date. Lifestyle changes include; getting married, 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 Student Benefit Plan(s), if they are within 30 days of losing coverage. If a student has lost their comparable coverage, they must provide documentation of loss by submitting a letter from either the insurance carrier or employer stating the date coverage ends, the carrier name and policy number.

Student Health and Dental 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. The Student will then be contacted by the 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 for the enrolment process to be completed.

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

Have a safe and healthy year!

Thank you

SAMRU Student Benefits Plan Office
Room Z001, Wyckham House
4825 Mount Royal Gate SW
Calgary, AB T3E 6K6
Phone: 403-440-6267 • Fax: 403-440-8980
Email: mtroyalplan@mystudentplan.ca

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. The Student will be contacted via email by the Benefit Plan Office 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. The Student must also be enrolled in the Student Health and Dental Plan.

IMPORTANT! The fees for Family Add-on are in addition to the student health and dental fee.

Spouse Eligibility

Spouse is defined as your spouse by marriage or under any other formal union recognized by law, or your common-law spouse.

Common-Law Spouse is a person who has been living with you in a conjugal relationship continuously for a period of not less than one year or who is the natural or adoptive parent of a child of who you are also the parent.

Spouse means the person who is a resident of Canada, and who is married to the student, or a person of either sex who has continuously cohabitating with the student for a period of at least one year and who is publicly represented as the student’s wife or husband.

Dependent Children Eligibility

Children are defined as your natural children, stepchildren, legally adopted children, and children for whom you/and or your spouse have been appointed as guardian(s) for all purposed pursuant to an Order of the Court. NOTE: if the child is your stepchild or your spouse’s adopted child or a child for whom your spouse has been appointed guardian, both your spouse and the children must reside with you full-time. In addition, the child must be:

Unmarried
Under 21 years of age and not employed full-time
Under 25 years of age, if they are attending a college or university full-time, or
Physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on the student for maintenance and support and while eligible under 1) or 2) above

NOTE: Parents, Grandparents, Siblings are not eligible dependents.

2019 - 2020 Family Add-On Fees:
Health (one or more dependent) $115.00
Dental (one dependent) $200.00
Dental (two or more dependents) $400.00

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

Have a safe and healthy year!

Thank you

SAMRU Student Benefits Plan Office
Room Z001, Wyckham House
4825 Mount Royal Gate SW
Calgary, AB T3E 6K6
Phone: 403-440-6267 • Fax: 403-440-8980
Email: mtroyalplan@mystudentplan.ca

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

Opt Out

NOTE: AB/Provincial Healthcare is not acceptable as alternate coverage.

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: Eligible students who have comparable health and/or dental coverage may apply to opt-out of the Student Health and/or Dental plan(s). The student is given one (1) opportunity to opt-out of the health and/or dental plan(s) each year. All opt-out forms must be completed online and must be received by the applicable deadline. The Student 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.

Approval of the Students opt-out will result in the plan fee being credited/or refunded according to the school's policy and will remain in force if the Student remains eligible.

If you are unsure if you are eligible for the Student Health and Dental plan, please contact the Benefit Plan Office prior to the applicable deadline.

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

Have a safe and healthy year!

Thank you

SAMRU Student Benefits Plan Office
Room Z001, Wyckham House
4825 Mount Royal Gate SW
Calgary, AB T3E 6K6
Phone: 403-440-6267 • Fax: 403-440-8980
Email: mtroyalplan@mystudentplan.ca