By clicking on this box you confirm that you are a student at North Island College.

Upgrading/high school Certificate/1 year program Diploma/2 year program Trades Undergraduate - BA/BSc Undergraduate - Business Undergraduate - Other University Transfer Program Graduate - Post-graduate diploma/certificate Graduate-Masters/PhD

Me (through an employer or other plan provider) My parent or guardian My spouse or common-law partner

Alberta Blue Cross Assumption Life Canada Life CIGNA Claim Secure Desjardins Insurance Empire Life Equitable Life of Canada First Nations Health Benefits Green Shield Canada Industrial Alliance Johnson Insurance Manulife Financial Medavie Blue Cross myGroupHealth Northern Financial Group Olympia Benefits Pacific Blue Cross Pacific Blue Cross Manitoba RBC Insurance SSQ Financial Group Standard Life Sun Life Financial Telus Health Solutions The Co-operators Wawanesa Insurance

Alberta Blue Cross Assumption Life Canada Life CIGNA Claim Secure Desjardins Insurance Empire Life Equitable Life of Canada First Nations Health Benefits Green Shield Canada Industrial Alliance Johnson Insurance Manulife Financial Medavie Blue Cross myGroupHealth Northern Financial Group Olympia Benefits Pacific Blue Cross Pacific Blue Cross Manitoba RBC Insurance SSQ Financial Group Standard Life Sun Life Financial Telus Health Solutions The Co-operators Wawanesa Insurance

First Name: Last Name: Date of Birth: Phone Number: Student Number: Email: Address Line 1: Address Line 2:City: Province: Postal Code: Country: Program Start Date: Grad/Undergrad:

Name of Person with Coverage: Relationship to you: Name of Employer(if applicable): Name of Alternate Health Provider: Health Policy or Group Number: Name of Alternate Dental Provider: Dental Policy or Group Number:

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.