This form is for people who wish to add their dependents and/or extend their coverage. Requests for changes must be received no later than 30 days after coverage begins.
IMPORTANT:This form extends your plan coverage to your dependent children and/or spouse for up to 12 months. After this period, you will need to re-enroll in a course with your educational institution and send us this form along with payment of the contribution during the modification period. In addition, be sure to contact Major Plan to find out the membership fee that applies to your situation.
Don’t forget to consult the “Authorizations and declarations” eligibility conditions at the bottom of the form.
To add dependents, you must extend your current coverage (add 8 months) and add your dependents for a period of 12 months.