SAMRU - Family Add-On 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 Family Add-On Application

Winter deadline to submit applications
January 26^th, 2024

Eligible students who meet the following eligibility criteria may apply to extend their benefits to their dependents before the applicable term deadline.

Health and Dental insurance fees on the student account are for the student only. Students must apply and pay additional fees to have their family members added.

Eligibility Criteria

There are 2 circumstances for adding family members to the Student Health and Dental Plan:

1 Academic Enrollment

Eligible students who wish to extend their benefits to their dependents may apply by the applicable term deadline according to the college enrollment:

New Students Enrolled in the Plan

New eligible students starting an eligible program as having full-time status.

Returning Students Active in the Plan

Returning eligible students on the anniversary of enrollment in the student benefits.

Winter deadline is January 26^th, 2024

2 Lifestyle Change

Students enrolled in the plan who have a lifestyle change such as getting married, meeting the twelve-month co-habitation requirement for common law status, or birth/adopting a child, who wish to extend their plan to their dependents may apply within 30 days of lifestyle change.

To apply, please email proof of Lifestyle Change to the Benefit Plan Office at mtroyalplan@mystudentplan.ca. If you are eligible to add family members, the office will send a link for the application.

Documentation includes a marriage certificate, birth certificate, or adoption documents.

Deadline is within 30 days of lifestyle change

Family Add-On Fees:

ONE FAMILY MEMBER		TWO OR MORE FAMILY MEMBERS
Health	$140	Health	$140
Dental	$200	Dental	$400
Health & Dental	$340	Health & Dental	$540

These are the current Family Add-on fees. However, the fees are subject to change without notice.
These fees are not included in your tuition, and you will pay them with a credit card on our website if your application is approved.
The Family Add-on fees cover 12 months of coverage for students staring in the Fall term and 8 months of coverage for students starting in the winter term.
The fees for Family Add-ons are non-refundable.

Important notes:

You can only extend your plan to your spouse or partner and your children. Parents, grandparents, and siblings are not eligible dependents to extend your plan. Please check the eligible dependents.
The family would be covered by the same plan the student has. The student and the family member do not share the coverage.
The family fees provide coverage for 12 months for applications approved in the Fall term and 8 months for applications approved in Winter term. The student needs to keep active in the plan for 12 months. If the student loses the coverage, the family loses the coverage too. The effective date of your coverage would be the 1^st day of the month when your program begins.
All plans are reset on September 1^st, and student need to submit a new Family Add-On application in the fall term to keep the family covered for a new benefits year.
Family Add-On requests & fees are not automatically renewed and must be submitted/paid every year.
There is a 45-day validation period from the start of the program. 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.
Each family member use the same card that the student has. The card must have the student's information (full name and student ID).
The fees for Family Add-ons are non-refundable.
NO EXCEPTIONS will be made if the application or payment is missed. It is the student's responsibility to check their emails regarding the application.
Once you complete the Family add-on form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting a Family Add-on request.

Steps to submitting your Family Add-On:

1 Student Information

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

2 Dependent Information

Scroll down and check Spouse/Child/Children according to the members you wish to add. Provide full name, initials, gender, and date of birth for each member. Click NEXT.

3 Read 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.

4 Confirmation 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.

5 Application Status

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

6 Pay Fees Online

If your application is approved, you will receive a link to pay the applicable fees with your credit card and the deadline to pay them.

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

Questions? Please contact your Benefit Plan Office: mtroyalplan@mystudentplan.ca

Health and Dental Family Add On Form

Please complete all information on the family add-on 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

FMU

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

Online Forms 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.

SAMRU Benefits Plan Office

Email: mtroyalplan@mystudentplan.ca
Phone: 403-440-6267
Address: Room Z001, Wyckham House
4825 Mount Royal Gate SW
4500-50 Street
Calgary, Alberta. T3E 6K6

General Inquiries Line

Monday to Friday from 6:00am to 5:00pm MST

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

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