Health Plan Premium Assistance Fund

READ THIS ENTIRE DOCUMENT BEFORE YOU APPLY.

Table of Contents

Who Is Eligible?

Any UBC, Regent College, VST, or St. Mark's student who has not opted out of the AMS/GSS Health and Dental Plan may apply for a reimbursement of part of their Plan fee. Please do not apply if you have opted out. The selection of applicants will be made on the basis of financial need.

Premiums for spouses and dependent children who are enrolled in the Plan are not eligible for reimbursement. If your spouse or dependent children are UBC, Regent College, VST, or St. Mark's students, they should apply separately.

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When Do I Get Reimbursed?

Refunds will be available by Thursday, November 15, 2018 and the Extended Health and Dental Plan Administrative Committee will contact you if your application is successful.

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How Do I Apply?

  1. Read this entire document.
  2. Print out a copy of this application form, and fill it out by hand before filling out the form online.
  3. Once you have figured out the correct numbers:
    1. fill-in the application form below on a computer,
      NB: Some applicants have been encountering problems when using Google Chrome. This problem appears to be caused by a bug in Google Chrome. Should your submission fail, please resubmit using Safari, Firefox, or Internet Explorer.
    2. submit the form by pressing the button at the bottom of the form,
    3. follow the instructions on the web page that is displayed after you submit the form,
    4. permit the Committee or staff employed by the Committee to verify any information submitted, and
    5. drop off (or mail in) supporting documents verifying your submission; please submit photocopies of your documents, and not the originals.
  4. Please note that the Committee reserves the right to request any other information from the applicants.

Please place your signed and dated print-out and supporting documents in a sealed envelope and either drop it off at the GSS Office between 9am to 5pm, Monday through Friday, or mail it to:

Graduate Student Society
6371 Crescent Road
Vancouver, BC
V6T 1Z2

All applications including supporting documentation must arrive at the GSS Office by Tuesday, September 25, 2018 at 4pm. It is your responsibility to ensure your entire application has been received by this time. We will not follow up on partial submissions. Should you decide to not apply for the bursary, then simply do not submit the required paper documents: this will automatically cause your application to be discarded.

All expenses and income should be declared with respect to the 12-month period from September 2017 to August 2018.

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Why am I asked for last year's income and expenses?

We ask for your actual income and expenses from the previous year as they are factual and not a projection. Should you feel that your financial situation from the previous year is not representative for your upcoming year, then consider including an additional information sheet with your application explaining why and how your expected situation will differ. The Committee may take this into account.

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Contact Information

Questions or problems about the Fund, application process, etc. should be directed to Ahmed Mtiraoui, preferably at his email address health@gss.ubc.ca. Alternatively, Ahmed will hold office hours at the GSS Office on Tuesdays from 1-5pm if you want to speak to him in person.

Technical errors with this web page or the submission process should be reported to Brian de Alwis.

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Application Form

Please fill in the information in each section as completely as possible. The name of each field is a link to an explanation of that field. Fields that do not apply to you should be either left blank or set to "0". Where appropriate, enter monetary amounts in Canadian funds; use whole dollar amounts only (no cents).

Many fields require supporting documents to be delivered or mailed to the GSS Office. Such documents must clearly show your name and the amount of income/expense. "DOC" indicates that documentation must be submitted. Additional documentation for other fields is not required, but can be used to support your application. When you submit the form, a list of these required documents will be displayed for you. Please note that the Committee reserves the right to request any other information from the applicants.

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Section 1: Personal Information

Please fill in this section completely. Applicants are required to have an email address.

Last name:
First name(s):
Street address:
City:
Province:
Postal code:
Telephone number: ()-
Email address:
Student number:
UBC/Regent/VST/St. Mark's program:
Which year of your program are you in?
How many years are there in your program?

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Section 2: Household Description

Do you live with your parent(s) or legal guardian? No Yes
Do you have a spouse or conjugal partner? No Yes
How many dependent children do you have? (DOC)
The income and expenses you declare below should include the amounts for your spouse or conjugal partner and dependent children.

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Section 3: Monthly Expenses

Enter average monthly costs for your household for the 12-month period from September 2017 to August 2018.

Rent or mortgage (DOC)$.00
Food$.00
Utilities$.00
Transportation$.00
Medical/dental$.00
Loan payments$.00
Student loan payments$.00
Child support/alimony payments$.00
Child care$.00
Clothing, haircuts$.00
Additional monthly expenses (DOC)

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Section 4: Monthly Income

Enter average monthly income for your household for the 12-month period from September 2017 to August 2018.

Net income from work and loans (DOC)$.00
Money from parents$.00
Child care subsidy$.00
Child support/alimony income$.00
Canada Employment & Immigration$.00
EI, WCB, VRS benefits$.00
Native band support$.00
Pension income$.00
Family allowance$.00
Welfare$.00
Additional monthly income

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Section 5: One-Time Expenses

Enter total one-time costs for your household for the 12-month period from September 2017 to August 2018.

Tuition (DOC)$.00
Books/supplies$.00
Household or Renter's Insurance$.00
Property taxes$.00
Additional one-time expenses (DOC)

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Section 6: One-Time Income

Enter total one-time income for your household for the 12-month period from September 2017 to August 2018.

Savings at start of term$.00
Sale of assets$.00
Bursaries and scholarships (DOC)$.00
Sponsored tuition/books$.00
Additional one-time income

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Section 7: Submitting the Application

By submitting this application, you agree that all of the above information is accurate. Should any of the information be found to be incorrect, you may be required to repay any monies granted to you under the Premium Assistance Fund. Furthermore, you authorize the Committee to contact any relevant institution and to request on your behalf information necessary to corroborate the above.

When you push the submit button, wait a few seconds. A page will appear detailing which accompanying documents you must submit (copies, not originals), as well as a privacy number. Your accompanying documents should be clearly marked with this number, on each page; this number will aid in maintaining your privacy and confidentiality. The AMS & GSS will make every reasonable effort to treat material you submit in the strictest confidence. Please print the page that appears and include it in your accompanying documents that you must deliver or mail to the GSS Office.

If there are errors in your form that can be automatically detected, the page that appears will detail these errors. You must then make corrections and resubmit the form until a successful submission occurs.

You may only make ONE (1) successful submission. Applicants with more than one application will be rejected. Make sure that the fields above are correctly filled out before submitting the form.

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