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University Health Insurance Plan (UHIP) Enrollment Form
Return this form to GO-ISSO Office,
4th Floor MacOdrum Library
or email to HYPERLINK "mailto:uhip@carleton.ca" uhip@carleton.ca
PLEASE PRINT CLEARLY:
Ӱԭ ID number: :_________________________________________
Surname: Name: _______________________________________________ First Name: ___________________________________
Date of Birth: ________________________________________ Gender: ( Male ( Female
(dd/mm/yy)
Complete this section only if your dependents (spouse and/or children) are with you in Canada:
Dependents date of arrival in Canada: ____________ Length of Coverage Requested: ____ month(s)
(YYYY/MM/DD)
Family Name
First NameRelationship
Spouse ChildGender
M/FDate of Birth
YYYY/MM/DD
( (
( (
( (
( (
( (
I am a/an:
( International Student with domestic status/paying domestic fees
( Diplomatic status
( Adding dependents
( Graduation pending
( Other (explain) _________________________________________________________
I declare that my answers in this application are true and complete and I understand that concealment, misrepresentation and false declaration concerning this application will cause the insurance to be void.
I authorize Cowan Assurance Company of Canada (the insurer), its agents and service providers and the UHIP plan administrator to use and exchange relevant information about me in connection with this application, for the purposes of underwriting, administration and adjudicating claims under this insurance coverage. The insurer is committed to keeping this information confidential.
I understand that UHIP is compulsory and I am responsible for enrolling my dependents on my date of arrival. If, however, my dependents arrive at a later date, I must enroll them within 30 days of their date of arrival in Canada. Otherwise, I will have to pay a late application fee of $500 and premiums retroactive to their date of arrival. I confirm that I am authorized to disclose information about my spouse and dependents in order to enroll them in this plan.
By signing below, I release the University from any responsibility for any undeclared dependents and for health care costs incurred by me or any of my dependents that are not eligible for reimbursement by UHIP or a pre-approved plan. I understand that the University will accept no financial liability for any such costs.
A photocopy or electronic version of this authorization is as valid as the original and will remain in effect for the duration of my coverage under the UHIP Plan.
Personal information collected through this form will be used and disclosed by Ӱԭ University under the authority of the Ӱԭ University Act, 1952, and in accordance with sections 39, 41 and 42 of Ontarios Freedom of Information and Protection of Privacy Act. The purpose of this processing is enrol you into the University Health Insurance Plan (UHIP).
The information will be used internally by International Student Services Office to manage the plan. Some information will be disclosed to Cowan Financial, the insurance plan administrator, in order for you to process benefits claims.
If you have any questions about the processing of personal information by International Student Services Office, please contact the Manager, Privacy & Access to Information, by phone at 613-520-2600 ext. 2047 or by e-mail via HYPERLINK "mailto:University_Privacy_Office@carleton.ca" University_Privacy_Office@carleton.ca.1
____________________________ ______________________________________
Date Members Signature
FOR OFFICE USE ONLY:
Premium Paid/Owing: _________________________
Effective Date of Coverage: _________________________________ Termination date: __________________________________
Length of Coverage ___________________ (months)
Number of Dependents: _____________________
SAR adjusted: ______________
Entered on PSS: ( Yes ( No Initials______________
Date processed: _____________________________________ Signature:___________________________________
August 2024
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