I understand that it is my responsibility to validate if I am still covered by the FEUS plan next fall if I am still a student and member of the association.

I have attached the necessary documents for the evaluation of this case (proof of loss of coverage, account statement or other documents).

I understand that, in the event I cancel the addition of dependent coverage after submitting my payment, Major Plan may deduct $40 from my refund as an administration fee.

I understand that payment of the contribution must be received no later than 12 business days after my form is submitted to Major Plan. If applicable, it is my responsibility to anticipate postal and banking delays. I understand that failure to forward my payment within these time frames will result in my application being cancelled without review.

I am aware of the conditions for maintaining my membership in the plan and understand that if I lose my student status in the winter semester, I will automatically lose my coverage with no possibility of a refund.

I am aware of the terms and conditions as well as the cost of the fee associated with this application and I agree to pay the fee. If in doubt, I have contacted Major Plan.

Please note that it is your responsibility to ensure that you receive confirmation of receipt of your application and payment from Plan Major. Contributions include, if applicable, premiums, administration fees, commissions, financial reserves and taxes that may be associated with the plan.