International Student Health Insurance

International Student Health Insurance

Opt-Out Request Form
You may request to opt-out of the health insurance plan offered through MITT if you provide proof of valid Manitoba Health coverage that covers the entire duration of your studies at MITT. Alternate health insurance plans will not be considered.

This form must be received by MITT by the opt-out deadline as indicated in the Opt-Out Deadlines section of the International Student Health Insurance webpage.

Submission of a second opt-out request form is required before starting Year 2 of a two-year post-secondary program
SECTION A: Student Information
Legal Name*

First/Given NameMiddle NameLast Name
Student Number*
Program Information

Program NameIntake
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Section B: Manitoba Health Coverage and Supporting Documents
Choose an option:

I confirm I have valid Manitoba Health coverageI have applied for Manitoba Health coverage and expect to be approved, but have not yet received my Manitoba Health Card
MB Health Start Date

MonthDayYear
Date
MB Health End Date

MonthDayYear
Date
I have applied for Manitoba Health coverage and expect to be approved, but have not yet received my Manitoba Health Card. I agree to the following:

Approval of my opt-out request is not guaranteedIt is my responsibility to submit supporting documents by the deadline communicated to me in an email from MITTManitoba Health CardManitoba health coverage letter or pink slip
Please upload either a copy of your Manitoba Health Card ONLY

Cancelof
Signature

Clear
Should be Empty:

International Student Health Insurance

SECTION A: Student Information

Section B: Manitoba Health Coverage and Supporting Documents