Forms

Please select a form

This Personal Information Form is to be used by students to provide 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 your coverage. You will receive an email notification from the Student Benefit Plan Office advising if any applicable fees and/or additional documentation is required to activate your coverage.

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

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

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 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 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.

EXTREMELY IMPORTANT: The student individual enrolment is NOT automatically renewed. In order for the student opt-in to continue, the student must purchase the coverage each benefit year before the applicable deadline.Please read and agree to the Terms & Conditions prior to submitting your online Enrolment Form.

Have a safe and healthy year!

Thank you

Student Benefit Plan Office
Bell e-Learning Centre
Room 921
4500-50 Street
Olds, Alberta T4H 1R6
Phone: (403) 556-4626 • Fax: (866) 860-3078
Email: oldsplan@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

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

OPT OUT

NOTE: Provincial Healthcare is not acceptable as alternative 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 at www.mystudentplan.ca/olds

Opting Out of coverage:
You have 1 opportunity at the start of your academic year to opt-out of the health and/or dental plan(s). If you previously opted out, your opt out will carry forward each year, as long as you remain an eligible student.

The deadline to Opt-Out is thirty (30) days after the start date of your program.NO EXCEPTIONS will be made if the deadline is missed. It is your responsibility to pay the plan fees, if you miss the applicable opt-out deadline.

Approval you 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.

Please read and agree to the Terms & Conditions prior to submitting your online opt-out.
If you are unsure if you are eligible, to confirm the applicable deadline or if you have any questions regarding the Student Health and Dental Plan, please contact the Student Benefit Office.

Have a safe and healthy year!

Thank you,

Student Benefits Plan Office
Bell e-Learning Centre
Room 921
4500-50 Street
Olds, Alberta T4H 1R6
Phone: (403) 556-4626 • Fax: (866) 860-3078
Email: oldsplan@mystudentplan.ca

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

Mailing Address

City

Province

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

Family Add On

You must be enrolled in the Student Health and Dental Plan to extend coverage to a spouse and/or dependent(s).

To add your spouse and/or dependent(s), complete and submit the Family Add-on form.

You will be contacted via email by the Benefits Plan Office about required supporting documents and fees. All supporting document(s) and fees must be paid by the applicable deadline to complete the family add on.

IMPORTANT! Family Add-on fees are in addition to the your 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 you, or a person of either sex who has been continuously cohabitating with you for a period of at least one year and who is publicly represented as the your 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 child 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) $195.00
Dental (one dependent) $195.00
Dental (two or more dependents) $320.00

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

Thank you

Student Benefits Plan Office
Bell e-Learning Centre
Room 921
4500-50 Street
Olds, Alberta T4H 1R6
Phone: (403) 556-4626 • Fax: (866) 860-3078
Email: oldsplan@mystudentplan.ca