By signing below I am indicating that…
I understand the information I provide on this form will be used by Student VIP, the Queen’s Society of Graduate & Professional Students (SGPS) and the financial services of the university for the purposes of administering my student health & dental plan.
I also understand that relevant information may be exchanged with the applicable insurer and/or third party insurance administrator acting on behalf of the insurer, as deemed necessary for the purposes of administration of my student health plan, validation of the status of my insurance coverage, and determining any eligibility for claimed benefits.
I hereby authorize the SGPS to exchange any relevant and necessary information with such parties for such purposes.
If I am applying for coverage for my eligible dependents, I confirm I am authorized to act on their behalf for such purposes.
I declare that the statements made on this form are complete and true.
I understand that if any statement is incomplete or false, any coverage granted may be voided.
Any true copy of this authorization shall be considered as valid as the original.