UHIP Dependant Application Form
Source: https://dnn.uottawa.ca/en/Utilities/Multiform/IO/UHIP-Dependant-Application-Form Parent: https://www.uottawa.ca/study/international-students/university-health-insurance-plan-uhip/dependants-coverage
General Comment
If your family members are moving with you to Canada and are eligible dependants, you must enrol them in the University Health Insurance Plan (UHIP) within 30 days of the date they became eligible for UHIP. UHIP membership is mandatory for all your dependants.
Dependants — your spouse and/or children — must be added to your UHIP account within 30 days of their arrival in Canada. Please note that late enrolment carries an additional fee of $500 per dependant.
This form is to be used only after you have enrolled in courses (which activates your uOttawa email) and your dependants have arrived in Canada.
Student information
Student Number*
First Name*
Last Name*
uOttawa Email Address*
Please provide a short explanation of the context of your request*
Dependant details
To add dependants to your UHIP account, please attach the following documents:
- A copy of the biographical information page of their passport (with name, gender, and date of birth).
- The page with their entry stamp to Canada.
Please specify the relationship of your dependant(s) below : spouse or child.
Fill in the sections 'Dependant #2-#5' only if you have more than one dependant to add. Make sure to populate all the fields including the attachments for each additional dependant.
Dependant details - Dependant #1
First Name*
Last Name*
Relationship*
Select Child Spouse
Date of Birth*
Year YYYY 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Month MM
Day DD
Gender*
Select Female Male Other Unknown
Supporting document - Biographic page (Max file size: 2 Mb)*
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Supporting document - Entry Stamp page (Max file size: 2 Mb)*
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Dependant details - Dependant #2
First Name
Last Name
Relationship
Select Child Spouse
Date of Birth
Year YYYY 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Month MM
Day DD
Gender
Select Female Male Other Unknown
Supporting document - Biographic page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Supporting document - Entry Stamp page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Dependant details - Dependant #3
First Name
Last Name
Relationship
Select Child Spouse
Date of Birth
Year YYYY 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Month MM
Day DD
Gender
Select Female Male Other Unknown
Supporting document - Biographic page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Supporting document - Entry Stamp page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Dependant details - Dependant #4
First Name
Last Name
Relationship
Select Child Spouse
Date of Birth
Year YYYY 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Month MM
Day DD
Gender
Select Female Male Other Unknown
Supporting document - Biographic page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Supporting document - Entry Stamp page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Dependant details - Dependant #5
First Name
Last Name
Relationship
Select Child Spouse
Date of Birth
Year YYYY 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Month MM
Day DD
Gender
Select Female Male Other Unknown
Supporting document - Biographic page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Supporting document - Entry Stamp page (Max file size: 2 Mb)
Accepted formats : jpg, jpeg, png, doc, docx, pdf.Choose fileChosen file:
Please leave this field blank:
Upon evaluation of the supporting documents, we will add the eligible dependants to your file and charge the premiums for coverage of dependants to your account. \ \ Learn more about UHIP coverage of dependants.