# 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

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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

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Student Number**\***

First Name**\***

Last Name**\***

uOttawa Email Address**\***

Please provide a short explanation of the context of your request**\***

Dependant details

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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
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1961
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1963
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1976
1977
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1980
1981
1982
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1984
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1988
1989
1990
1991
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1994
1995
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1997
1998
1999
2000
2001
2002
2003
2004
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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.
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Learn more about **[UHIP coverage of dependants](https://www.uottawa.ca/current-students/health-insurance/dependants)**.