Family Add On Form

IMPORTANT: These fees are in addition to the student health and dental fee.

2017 - 2018 Family Add-On Fees:

Health (one or more dependent)	$135.00
Dental (one dependent)	$160.00
Dental (two or more dependents)	$290.00

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 RRCSA Student Benefits 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.

2017 - 2018 Family Add-On Fees:
Health (one or more dependent) $135.00
Dental (one dependent) $160.00
Dental (two or more dependents) $290.00

International Family Add-On Fees:

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

Sex

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

Service Members

Find a Practitioner/Pharmacy

Find a Practitioner Select List

Find a Practitioner text box

Opt Out
Deadline: 30 Days from the official start date of your program

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Based on the Manitoba Provincial Formulary

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Family Add On Form

Family Add On

Student Information

Service Members

Opt-Out/In & Family