• Extended Health Benefits (EHB) Fund

    ***** THIS FORM IS NO LONGER IN USE. *****

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    *** Please note that this form is no longer in use and will be deactivated by September 31st. All applications currently in process will not be affected. ***
     
     
    *** TO SUBMIT AN APPLICATION TO THE EXTENDED HEALTH BENEFITS FUND, PLEASE USE THE FOLLOWING LINK: https://form.jotform.com/cupe3903/2026-ehb-fund-form ***
  • Application Status

  • Member Information

  • It looks like you've entered a York email address. Please enter a non-York email address to submit this form.

  • Format: (000) 000-0000.
  • Bargaining Unit*
  • End date of most recent CUPE 3903 contract*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Fund Request

  • My request is for:*

  • Paid Expense

    This section is for expenses for which you have already paid and have the necessary receipts.

  • Please group together similar expenses as one expense rather then as multiple expenses. For example, if you are seeking reimbursement for 5 massages, total up the amounts, and treat it as a 1 expense type.

    • Expense #1 
    • Reason*
    • Expense #2 
    • Reason*
    • Expense #3 
    • Reason*
    • Expense #4 
    • Reason*
    • Expense #5 
    • Reason*
    • Total Expense (Paid) 

  • Foreseeable Expenses

    This section is for expenses that you have not yet paid for and for which you have estimates or invoices.

  • Please group together similar expenses as one expense rather then as multiple expenses. For example, if you are seeking funding for 5 upcoming therapist sessions, total up the expected amounts, and treat it as a 1 expense type.

    • Expense #1 
    • Reason*
    • Expense #2 
    • Reason*
    • Expense #3 
    • Reason*
    • Expense #4 
    • Reason*
    • Expense #5 
    • Reason*
    • Total Expense (Foreseeable) 

  • Supporting Documents

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  • Additional Information

  • Although this is not required, a short explanation of the expenses you claimed and the reason you are applying to EHB can help the committee to understand your application. This may include background information about the provider, product, or service, your overall health status, or other circumstances contributing to additional hardship.

    This information may also take into account intersecting issues relevant to your financial situation and the health issues for which you are seeking funding, including overall health, family or financial situation, and/or social marginalization on the basis of race, ethnicity, class, sexuality, gender, or ability.

  • Submission

  • Certificate

    I certify that all information presented herein is accurate to the best of my knowledge.

  • The Extended Health Benefits Committee strives to meet to adjudicate applications once per month due to the possibly urgent nature of the expenses. Once the Committee has adjudicated, members will be informed as to the result of the application. Should the Committee require additional information, the Committee will email the member with the provided email, though this will cause a delay in the adjudication of the file.

     

    Please press the Review button to review your application prior to submission. Upon submission, you will receive an automated email from the Committee confirming receipt.

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