USC - PurpleCARE - 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

Fall 2024 deadline to submit applications
Monday, September 23^rd, 2024, 11:30 PM

Eligible students who are enrolled in the Benefit Plan may apply to extend their coverage to their dependents by the applicable 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 Fall Term

Eligible students who wish to extend their benefits to their dependents may apply each fall term by the applicable fall deadlline.

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.

If an application is approved, students receive an email with a link to process the payment and a deadline. Students must pay the additional fee by the deadline informed in the mail to activate the family coverage.

Fall 2024 deadline is Monday, September 23^rd, 2024, 11:30 PM

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/adoption of 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 healthdental@westernusc.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 OR MORE FAMILY MEMBERS
Health	$525.03
Dental	$506.63
Health & Dental	$1,031.66

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 from September 1^st to August 31^st next year.
The fees for Family Add-on are non-refundable.

Important notes:

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 one year. The student needs to be enrolled 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 September 1^st.
Family Add On requests & fees are not automatically renewed and must be submitted/paid every year.
If you are appling because of lifestyle change, you must provide the proper documentation and complete the online form defore the applicable deadline. Documentation includes a marriage certificate, birth certificate or adoption documents. This documentation must be emailed to healthdental@westernusc.ca. Otherwise, your application will be denied.
There is a 45-day validation period from the start of the term. During this time, family members would have to pay out of pocket for all eligible Health and Dental expenses and keep the receipts. After the enrollment process is complete, the stundent will be able to submit online claims for reimbursement and the Plan Card will be automatically activated form the family members.
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-on are non-refundable.
NO EXCEPTIONS will be made if the application or payment is missed. It is the student's responsibility to check their BVC emails regarding deadlines.
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 a Family Add-On Application:

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: healthdental@westernusc.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

F

M

U

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

Fall Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by September 23^rd, 2024 at 11:30 PM

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.

USC Benefits Plan Office

Email: healthdental@westernusc.ca
Address: University Community Centre
Room #320
1151 Richmond St
London, Ontario N6A 2K5

General Inquiries Line

Monday to Friday from 8:00am to 7:00pm EST

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

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Online Forms

Health and Dental Family Add-On Application

Eligibility Criteria

Family Add-On Fees:

Steps to Submitting a Family Add-On Application:

Health and Dental Family Add-On Form

The fall 2023 opt-out deadline is closed.

Health and Dental Family Add-On Form

Student Information

USC Benefits Plan Office

General Inquiries Line

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