Health Plan Form

Niagara College Student Administrative Council Inc.

Individual Student Opt IN Form 2020-2021

This form is to be used ONLY when a student does not normally qualify for benefits.

NOT AVAILABLE FOR SPRING/SUMMER TERM!

STUDENT INFORMATION *mmandatory

First Name

Surname

Student ID#

Phone Number

Address

Comments

Thanks for your order!

DOB

Niagara College Student Administrative Council Inc.

Individual Student Opt IN Form 2020-2021

This form is to be used ONLY when a student does not normally qualify for benefits.

NOT AVAILABLE FOR SPRING/SUMMER TERM!

STUDENT INFORMATION *mandatory

First Name

Surname

Student ID#

DOB

Please Indicate your Gender Preference

What Program are you In?

Which campus do you attend?

Phone Number

Home Mailing Address

City

Postal Code

After reviewing the flex plan options found on , please indicate below which Flex Plan Option you would like to enroll in.

Please indicate one of the following options:
Balanced, Enhanced Drug/Vision, Enhanced Dental/ Vision, Enhanced EHC/Vision.

Which plan would you like?

This form is to be used ONLY when a student does not normally qualify for benefits. If you are a full-time fee paying student, you do NOT complete this form. By clicking 'Proceed to Checkout' you are agreeing that the above information is accurate, and true.

Thanks for your order!

Domestic Student Health Plan - Opt In

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If you are not currently enrolled in the health plan, but would like to be, you can use the form below to opt in.

Niagara College Student Administrative Council Inc.

Niagara College Student Administrative Council Inc.

Domestic Student Health Plan - Opt In

Powered by We Speak Student

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