Dependents Enrolment Form

"*" indicates required fields

Family enrolment forms for Winter 2022 are now being accepted.

Part-time undergraduate degree students access coverage for medical expenses such as prescription drugs and dental treatments through CESAX. These benefits can be extended to a spouse and/or dependent children for an additional fee. To add eligible dependents, complete the sections below. 

***DEADLINE TO ENROL DEPENDENTS: FEBUARY 11TH AT 5:00PM***

For more information, please visit our website at www.mycesax.ca/health

Or contact the CESAX Health Plan Administrator at: healthplan@mycesax.ca

For detailed plan information visit https://www.greenshield.ca/en-ca/student-centre/cesar-continuing-ed-ryerson-csr

*Benefits are only available to CESAX members who are enrolled in a part-time degree program

Please select one of the following:*
Gender*
dd/mm/yyyy
DD slash MM slash YYYY
Please note that your Green Shield ID is CSR + Your Student Number -00

Family Information

Please ensure that all information is correct.

How many dependents are you hoping to enrol?*
(suffix -01)
Gender 1
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -02)
Gender 2
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -03)
Gender 3
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -04)
Gender 4
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -05)
Gender 5
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -06)
Gender 6
(DD/MM/YYYY)
MM slash DD slash YYYY
(suffix -07)
Gender 7
(DD/MM/YYYY)
MM slash DD slash YYYY
If I already have existing coverage, I can combine benefits with my existing plan to have 100 percent coverage.*

BY COMPLETING THIS FAMILY APPLICATION FORM, YOU AGREE TO THE FOLLOWING:

I confirm that the information provided above is accurate. I understand that the information above is required in order for me to provide the same extended health and dental benefits, as outlined in the benefits plan booklet available online at www.greenshield.ca/studentcentre, excluding tutorial benefits, to my spouse and/or dependent children. I further understand that Accidental Death and Dismemberment benefits offered by ACE INA are for members only and are NOT available to my spouse and/or dependent children. I authorize the use of this information where it is required, and I am aware that this information will not be used in any manner except to administer the plans in accordance with TMAPS policy.

Once eligibility is confirmed, someone in our office will contact you to process the payment and complete your application.