Student Information   My Existing Coverage   Summary 

First Name: Last Name: Date of Birth: Phone Number: Student Number: Email: Address Line 1: Address Line 2:City: Province: Postal Code: Country: Program Start Date: Grad/Undergrad:

Name of Person with Coverage: Relationship to you: Name of Employer(if applicable): Name of Alternate Health Provider: Health Policy or Group Number: Name of Alternate Dental Provider: Dental Policy or Group Number:

Submission of this form constitutes an agreement between the Students’ Union and the person listed as the student seeking to opt out.

By clicking submit, I certify all information is true and correct and I agree to the terms and conditions of the opt-out process and wish to opt out of the health, dental, travel and other such coverage being made available to me as part of the Students’ Union’s plan.

I further acknowledge that, once opted-out, I waive my rights to re-enter the plan unless I meet the conditions set forth by the Students’ Union. I acknowledge that the Students’ Union may deny me access to rejoining the plan if the information I have submitted in this opt out request is false, or at their discretion, may have the appropriate fees re-applied to my student account and return me to the plan retroactive to my submission of false information.