GSA Carleton Health and Dental Winter 2023

GSA Carleton Health and Dental Opt In Form

PLEASE READ CAREFULLY: This is the opt-in application is for new January 2023 start students. This includes full-time, part-time, and co-op students beginning as a new Carleton University graduate student in January 2023. These students may also elect to opt-in a spouse, common-law partner, and/or dependent children. If you elect to opt in dependents, you need to pay for the INDIVIDUAL coverage AND the appropriate DEPENDENT coverage. Students who began studying in Fall 2022 are not eligible to opt-in at this time. The coverage period for the Winter 2023 opt-in is January 1, 2023 to August 31, 2023. This is a secure form for the purposes of opting into health and dental coverage or opting in your dependents. If you need any help navigating the form or understanding the choices, please email gsa@gsacarleton.ca or occ@gsacarleton.ca for assistance.
Student Number*
Full Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Gender Identity*
As indicated on your provincial health card or UHIP card
Phone Number*

Area Code Phone Number
E-mail*
example@example.com
Address*

Street Address

Apt or Suite (if applicable)

City Province

Postal Code
Have you already paid the GSA Health and Dental Insurance Fee of $412.69, through Carleton University (per your Carleton Central account statement)?*

Yes I have, I am only going to opt in dependents.No I have not, I am going to opt in myself and dependents.No I have not, I am going to opt in only myself.

Dependent Information (if applicable)

Fill in your dependent(s) information here if you are applying additional coverage.
Spouse or Dependent 1 Name

First Name Last Name
Spouse or Dependent 1 Relationship to Student

Spouse/Common Law PartnerDependent Child
Spouse or Dependent 1 Date of Birth

MonthDay Year
Date of Birth
Spouse or Dependent 1 Gender Identity
As indicated on their provincial health card or UHIP card
Additional Dependents (separate each individual's information with a comma):
Please note you MUST include the first and last name, date of birth (mm-dd-yyyy format), gender identity (female, male, or undisclosed), and relationship (spouse or child) for each of your dependents. Any missing information will delay your enrolment and will not let us process your dependents.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

GSA Carleton Health and Dental Opt In Form

Dependent Information (if applicable)

Select Your Coverage