Opt In Form | Gallivan

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 Re-enroll

All new eligible domestic and international students are automatically enrolled in the Health and Dental plan so only submit a re-enrollment form if you have previously opted out of the plan or meet the special eligibility criteria for students not automatically eligible.

Eligibility Criteria

There are 4 scenarios for re-enrolling or opting in to the Student Health and Dental Plan:

1 Students not-eligible automatically for the Plan

Opt-In application

Students may apply to opt-in to the Student Plan if they are in one of the following situations:

Students starting their program or school in January
Students undergrad taking fewer than 9 Fall semester credit hours
Graduate student taking fewer than 6 Fall semester credit hours
Co-op Students
Students enrolled in the ATP/ ARP programs

2 Program Start Date

Re-enroll aplication

Students who previously opted out of the benefits and are still eligible for the Student Plan may apply to re-enroll in the Student Plan at the anniversary term of starting their program

The Winter deadline to apply is January 31^st, 2021.

For example: 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

3 Loss of Comparable Coverage

Students who have lost their comparable insurance coverage and are still eligible for the Student Plan may re-enroll in the plan. You must provide the proper documentation by emailing admin@ursu.ca and completing the online form.

The deadline to apply is within 30 days of losing that coverage

4 Lifestyle Change

Students who previously opted out of the benefits, are still eligible for the Student Plan, and have experienced a lifestyle change may re-enroll in the plan. You must provide the proper documentation by emailing admin@ursu.ca and completing the online form.

The deadline to apply is within 30 days of the change date

Opt-In/Re-enroll Fees:

Fall Term		Winter Term
Health	$98.30	Health	$65.32
Dental	$120.20	Dental	$80.13
Health & Dental	$218.50	Health & Dental	$145.45

Important notes:

The effective date of your coverage is the 1^st day of the term when your program begins.
There is a 60-45-day validation period from the start of your 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 benefits card will be automatically activated.
NO EXCEPTIONS will be made if the deadline is missed.
Once you complete the opt-in or re-enrollment form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting a request.

Steps to submitting your opt-in or re-enrollment form:

1Student Information

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

2Enrolment Circumstances

Scroll down and check Health Plan/Dental Plan/Qualify. You can choose Health or Dental or both plans. Select your status and Click NEXT.

3Read 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.

4Confirmation 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.

5Application status

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

6Pay the fees

If your application is approved, the fees will be included in the student account.

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

Questions? Please contact your Benefit Plan Office: admin@ursu.ca

Health and Dental Re-enroll Form

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
Add Family or Opt-in
Submit your applications before: January 31^th, 2023

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