GSA Carleton Health and Dental

GSA Carleton Health and Dental Opt In Form

PLEASE READ CAREFULLY: This is a secure form for the purposes of opting in to health and dental coverage, or opting in your dependents. If you have not paid the GSA health and dental insurance fee through your Carleton Central account (the amount is $410.89, as can be seen in your fee statement), and you need to opt in dependents, you need to pay for the INDIVIDUAL coverage AND the appropriate DEPENDENT coverage. If you need any help navigating the form or understanding the choices, please email gsa@gsacarleton.ca for assistance. Please ensure you have flash enabled if you are using Google Chrome, otherwise your payment may not go through.
Student Number *
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender Identity *
Phone Number *

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

Apt # if applicable

Street Address

City State / Province

Postal / Zip Code
Have you already paid the GSA Health and Dental Insurance Fee, through Carleton (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 dependents here if you are applying additional coverage.
Spouse or Dependent 1 Information:

First Name Last Name
Date of Birth

Month Day Year
Date
Gender identity
Additional Dependents(separate each individual's information with a comma):
Please note you MUST include the name, date of birth and identity for your dependents. Any missing information will delay your enrolment and will not let us process your dependents.

GSA Carleton Health and Dental Opt In Form