Rescind Waiver Online Application
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.
Student ID Number *
Program Name *
Your Status *
Campus Study *
First Name *
Last Name *
Date of Birth *
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Gender *
Phone Number *
Email Address *
Complete Mailing Address including Postal Code *
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
Clear selection
Please explain in detail the reason(s) for your request to rescind waiver/opt out application: *
If you completed the rescind waiver/opt in application in the past. Please provide the Month and Year when you completed the application in the past.
Date of Loss of Alternative Coverage *
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Date of Commencement of Restored Coverage *
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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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