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Application for Family Coverage

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									ASSOCIATION OF PART-TIME UNDERGRADUATE STUDENTS APUS Health & Dental Plan Family Coverage Form 2009-2010
Application Deadlines to Opt-In: Fall Term: Monday, August 24, 2009 – Friday, October 23, 2009 Winter Term: Monday, January 4, 2010 – Friday, February 5, 2010 (Winter Term Opt-in: Only applies to part-time students not registered for any courses during the Fall term.) Who may apply for Family Coverage? You must be a registered part-time undergraduate student at the University of Toronto to apply for Family Coverage (please see definition of part-time on back of the form). Please choose only one of the following: A. Family Health coverage only additional fee of $119.66 (full year) B. Family Dental coverage only additional fee of $48.96 (full year) C. Both Family Health and Dental coverage additional fee of $168.62 (full year) ________ ________ ________

Who is Covered: Family coverage is defined as: your spouse (including a common law or same sex partner) and/or children. Dependent children include your unmarried children, stepchildren and legally adopted children who reside with you and are dependent upon you for support and are: a) younger than age 21; b) age 21 and up to 25 years of age and in full-time/parttime attendance at an accredited institute of learning and dependent on you for support; or c) 21 years or older and mentally or physically disabled and incapable of self-sustaining employment who was insured under this policy as a Dependent on the day prior to his/her 25th birthday and remains dependent on you for support. All family members enrolled for coverage under this plan must be residents of Canada.

STUDENT (PLEASE PRINT)
Surname: 9 digit Student No: Street Address: City & Province: Home/Cell Phone: ( Given Name(s): Date of Birth (MM/DD/YY): Apt/Unit No: Postal Code: Business Phone: ( ) / /

)

SPOUSE/DEPENDENT CHILDREN (PLEASE PRINT)
Surname: Given Names: Relationship:
DOB (MM/DD/YY)

Suffix
01 02 03

/ / /

/ / /

I enclose payment according to the above checked options for Family Coverage in the Association of Part-time Undergraduate Students (APUS) 2009-2010 Health Plan: Signature of Student
Information on this form will be kept strictly confidential. Please check: St. George/UTM student _____ / UTSC student _____ Please check: Fall 2009 ONLY _____ / Winter 2010 ONLY _____ Please pay half of the Family opt-in fee if you are only enrolled in classes for half a term. Your coverage will extend for the following periods depending on the term registered: Fall Term – September 1, 2009 to February 28, 2010; Winter Term – March 1, 2010 to August 31, 2010. Note: For those who take classes for only one term, they can only opt their family members in for that term. Form of Payment (please check only one): _____ Cheque or Money Order (payable to the Association of Part-time Undergraduate Students) / _____ Cash (Do NOT send cash in the Mail)

Date

Please return in person or mail this form with payment to the following address: Sidney Smith Hall, Room 1089, 100 St. George Street, Toronto, ON M5S 3A3

ASSOCIATION OF PART-TIME UNDERGRADUATE STUDENTS APUS Health & Dental Plan Family Coverage Form 2009-2010
For more information:
Please contact APUS at (416) 978-3993, or at info.apus@utoronto.ca, or visit our website at www.apus.utoronto.ca. For a complete explanation of our Plan, please visit http://www.greenshield.ca/English/StudentCentre/

Definition of a UofT Part-time Undergraduate Student for the purpose of the APUS Health & Dental Plan: St. George & UTM: If you are registered in 2.5 credits or less during the entire 2009-2010 Fall & Winter sessions, and you have been charged APUS fees, you are a part-time student and an APUS Health & Dental Plan member. UTSC: If you are registered in 1.0 credits or less during either the Fall 2009 or the Winter 2010 sessions and you have been charged APUS fees, you are a part-time student and an APUS Health & Dental Plan member. Co-op students NOT enrolled in any courses are not charged APUS fees.

PLEASE FILL OUT AND RETURN THIS APPLICATION TO THE FOLLOWING LOCATION: Please retain a copy for you records. ST. GEORGE: APUS ST. GEORGE OFFICE: PHONE: (416) 978-3993; FAX (416) 971-1393 APUS STUDENT SERVICES OFFICE, SIDNEY SMITH HALL, ROOM 1089, 100 ST. GEORGE STREET TORONTO, ON M5S 3A3


								
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