DG
DENTAL GRANT APPLICATION
The Dental Grant is designed to assist graduate students in off-setting the cost of any urgent and necessary dental repairs or other dental services, which are covered at less than 50% by the GSA's dental insurance plan. It was created with the understanding that graduate students are sometimes faced with significant dental expenses. 1. The Dental Grant may be awarded to a maximum of $750 per student (including dependent(s) as defined under the GSA's dental insurance plan) each policy year. The amount awarded will not exceed 50% of the graduate student's total dental expenses, including the portion reimbursed under the dental insurance plan. 2. The allotment for the Dental Grant Fund is $5000 per fiscal year, although surpluses from previous years may be added. Grants will be awarded on a "first come, first served" basis until the fund is depleted. 3. Each graduate student applying for the Dental Grant must submit a completed Dental Grant application form, as well as documentation from his or her dentist. 4. Dental Grants will be awarded on a case-by-case basis by the VP Finance or designate and one other member of the Executive, normally within five (5) business days.
PERSONAL INFORMATION
FAMILY NAME GIVEN NAME(S)
RELATIONSHIP TO POLICYHOLDER
STUDENT NUMBER
DEPARTMENT
DEGREE PROGRAM
LOCAL ADDRESS
POSTAL CODE
EMAIL ADDRESS
LOCAL TELEPHONE NUMBER
NATURE OF THE DENTAL WORK AND CIRCUMSTANCES
Please provide a detailed explanation
DOCUMENTATION REQUIRED
1. Letter from the Insurance company, stating how much they cover 2. Letter from Dentist, confirming that the dental procedure is urgent and necessary
FOR OFFICE USE ONLY
DATE RECEIVED INITIALS
AMOUNT APPROVED
APPROVED BY
VP FINANCE EXECUTIVE DATE DATE
COMMENTS
REQUISITION NUMBER