University Health Insurance Plan (UHIP) Opt-Out Form

Name*

First Last

Carleton Student ID Number*

Please enter a number from 100000000 to 999999999.

9 Digit Student ID Number

Carleton Email*

Enter Email Confirm Email

Where are you residing during the Fall 2022 Term at Carleton University?*

Inside Canada
Outside of Canada

Where are you residing during the Winter 2023 term at Carleton University?*

Inside Canada
Outside of Canada

If you are residing outside Canada, do you have an anticipated date of arrival to Canada?*

Yes
No

For additional guidance on planning your travel to Canada, kindly consult our Quarantine Planning Support Website.

What is your anticipated date of arrival in Canada?*

Do you have family members who will be accompanying you to Canada for your studies (spouse and/or children)?*

Yes
No

Dependents must be enrolled separately within the University Health Insurance Plan. Please note, that you must request to re-enroll your dependents in UHIP each academic year. Questions? Contact the ISSO at isso@carleton.ca

Any additional comments?

By clicking this box, I hereby certify that I will be residing and studying outside of Canada for either the entire Fall 2022 or Winter 2023 term (or both) and I am therefore opting out of coverage for that period.*

Confirmed

I acknowledge and agree that it is my responsibility to notify the ISSO before I plan on travelling to Canada in order to reinstate my coverage. Once opted out of coverage I understand and agree that I will only be reinstated once I notify the ISSO in writing that I am travelling to Canada.*

Confirmed

I acknowledge that enrolment in the University Health Insurance Plan (UHIP) is mandatory for eligible international students, and their dependents, when they come to Canada.*

Confirmed

I acknowledge and agree that UHIP fees are determined by Sun Life and that reinstating coverage will result in premiums being charged to my Carleton student account.*

Confirmed

I acknowledge and agree that my decision to travel is my personal decision and that my entry into Canada is subject to Canadian immigration laws including but not limited to mandatory quarantine orders. I acknowledge and agree that it is my obligation and responsibility to familiarize myself with all requirements to enter and stay in Canada.*

Confirmed

I certify that the information submitted is to the best of my knowledge and belief, true, accurate and complete. I understand and agree that false or misleading information will have consequences to my UHIP coverage and immigration status.*

Confirmed

Personal information collected through this form will be used and disclosed by Carleton University under the authority of the Carleton University Act, 1952, and in accordance with sections 39, 41 and 42 of Ontario’s Freedom of Information and Protection of Privacy Act. The purpose of this processing is enroll you into, and manage your registration with, the University Health Insurance Plan (UHIP). The information will be used internally by International Student Services Office to manage the plan. Some information will be disclosed to Sun Life Financial, the insurance plan administrator, in order for you to process benefits claims. If you have any questions about the processing of personal information by International Student Services Office, please contact the Manager, Privacy & Access to Information, by phone at 613-520-2600 ext. 2047 or by e-mail via University_Privacy_Office@carleton.ca.

CAPTCHA

Ineligible for UHIP Opt-out

You have indicated on the form that you are an international student currently residing in Canada for the Fall 2022 term. Accordingly, your enrolment in the University Health Insurance Plan (UHIP) continues to be mandatory and you are not eligible to opt out of coverage for this period. For more information about the UHIP plan, and coverage details please visit our website.

University Health Insurance Plan (UHIP) Opt-Out Form (Fall 2022/Winter 2023)

Ineligible for UHIP Opt-out