Rescind Waiver Online Application
The Student Association of George Brown College benefits plans are supplemental coverage to basic medicare, providing coverage for medical expenses not covered by provincial medicare, such as prescription drugs and dental care. If any student demonstrates existing comparable coverage, the health and dental benefits plans can be waived for the duration of the student’s full-time studies at George Brown College. If a student’s comparable coverage is terminated, the student must inform the Student Health Benefits Office within thirty-one (31) days from the loss of coverage date to be covered by the
student benefits plans. ONLY THE STUDENT HEALTH BENEFITS OFFICE CAN PROCESS YOUR RESCIND WAIVER FORM.
Your status
Required
Student ID Number
Your answer
Program Name
Your answer
Campus Study
Required
Are you Domestic or International Post-Secondary Student
If you are an International Post-Secondary Student; please select which insurance plan you wish to opt-in
First Name
Your answer
Last Name
Your answer
Date of Birth (YYYYMMDD)
Please type in this format ONLY:19870525 (YYYYMMDD) No other format will be accepted.
Your answer
Gender
Required
Phone Number
Your answer
E-mail address
Your answer
Complete address including postal code
Your answer
Please explain in detail the reason(s) for your request to rescind waiver/opt out application:
Your answer
Date of Loss of Alternative Coverage
MM
/
DD
/
YYYY
Date of Commencement of Restored Coverage
MM
/
DD
/
YYYY
The plan I am choosing is (choose one of the following):
There are 4 different plans you can choose from at no additional cost. To review the plan overview, you can visit https://wespeakstudent.com/home/47-george-brown-college/domestic-plan
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