Student Information   My Existing Coverage   Summary 

Submission of this form constitutes an agreement between the Students’ Union and the person listed as the student seeking to opt out.

By clicking submit, I certify all information is true and correct and I agree to the terms and conditions of the opt-out process and wish to opt out of the health, dental, travel and other such coverage being made available to me as part of the Students’ Union’s plan.

I further acknowledge that, once opted-out, I waive my rights to re-enter the plan unless I meet the conditions set forth by the Students’ Union. I acknowledge that the Students’ Union may deny me access to rejoining the plan if the information I have submitted in this opt out request is false, or at their discretion, may have the appropriate fees re-applied to my student account and return me to the plan retroactive to my submission of false information.