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.
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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.
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Select your Coverage:
Categories:
All
All
Individual or Student Coverage
Couple or 1 Dependent Coverage
Family Coverage
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next
( X )
test
$
1.00
CAD
test
Individual or Student Coverage
Individual Health Coverage
$
207.00
CAD
Individual health coverage for the student. This does not include health coverage for dependents.
Individual Dental Coverage
$
204.00
CAD
Individual Dental Coverage for the student. This does not include dental coverage for dependents.
Quantity
1
2
3
4
5
6
7
8
9
10
Individual Health and Dental Coverage
$
411.00
CAD
Individual Health and Dental Coverage for the student. Does not include any dependents.
Couple or 1 Dependent Coverage
Couple or 1 Dependent Health Coverage
$
207.00
CAD
Additional Health Coverage for Spouse or 1 Dependent.
Couple or 1 Dependent Dental Coverage
$
204.00
CAD
Additional Dental Coverage for Spouse or 1 Dependent.
Couple or 1 Dependent Health and Dental Coverage
$
411.00
CAD
Additional Health and Dental Coverage for Spouse or 1 Dependent.
Family Coverage
Family Health Coverage
$
440.00
CAD
Additional Health Coverage for more than 1 dependent.
Family Dental Coverage
$
480.00
CAD
Additional Dental Coverage for more than 1 dependent.
Family Health and Dental Coverage
$
920.00
CAD
Additional Health and Dental Coverage for more than 1 dependent.
Total
$
0.00
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Place Order
Should be Empty: