2014 -2015 Academic year
Coverage runs through to August 31, 2015
Health Plan OPT-IN form
As a SOGS member, a graduate student on leave or a UWO Post Doctoral Fellow, I am exercising my
option to opt-in to the extended health plan provided by the Society of Graduate Students (SOGS) at
UWO. I have received and read the information provided and agree to pay the opt-in premium.
Winter 2015
Full Time
Part Time
* LOA & Post-Docs
Student Name:
Single
Included on Tuition Fee Bill
$422.60
$449.85
+ 1 dependant
$290.45
$833.00
$860.20
+ 2 or more dependants
$580.85
$1,243.35
$1,270.55
__________________________________________
Surname
Student Info:
______________________________
First Name
______________________________________________
E-mail address
______________________________
Student Number
________________________________
Date of Birth
(MM/DD/YY)
_________
(________)_____________________
Male/Female
Phone Number
Eligible Dependant(s) to be insured
Please Print:
Surname
First Name
Gender
Date of Birth
(MM/DD/YR)
Spouse:
__________________________________,
____________________
______
____________
Children: __________________________________,
____________________
______
____________
__________________________________,
____________________
______
____________
__________________________________,
____________________
______
____________
__________________________________,
____________________
______
____________
__________________________________,
____________________
______
____________
* LOA & Post-Doctoral: I hereby certify the above is a Student on Leave or a Post-Doctoral Fellow; and
I have attached documentation validating his/her status…
Department Info: ______________________________________________
Department Chair/ Supervisor
______________________________
Signature
_______________________________
Department
________
______________________________
Ext. #
E-mail
Deadlines:
Full-Time, Part-Time & Students on Leave
Post-Doctoral Fellows
January 31, 2015
2 months from the date of enrolment this academic year
Student Signature: ____________________________________________
DATE: _______________________