COLLEGE MEDICAL WITHDRAWAL CERTIFICATE
STUDENT INFORMATION RELEASE
To be completed by the Student, Parent or Guardian
STEP 1
Name of Insured Student
Name of Tuition Payer

 		 Social Security #:
Social Security #:
 
I HEREBY AUTHORIZE the College/University to release the information requested below and other such information which is necessary to verify my withdrawal from the College/University to A.W.G. Dewar, inc. for their use in documentation of claim for recovery of college fees from the insurance contract in effect at this time.  In the event there is an unpaid balance on my account at the time of withdrawal, I authorize A.W.G. Dewar, Inc. to pay the proceeds of the claim to the College/University for credit to my account.  Benefits not required to settle my account will be refunded to me.
Date Select Date
 		    Signature
(student if legal age, or parent or legal guardian)                      
Parent's / Student's Permanant Address
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

STEPS II (A) and (B) should be completed by the College/University and mailed to A.W.G. Dewar, Inc., 4 Batterymarch Park,
Quincy, MA 02169-7468 as soon as possible; in any event, not later than 30 days after date of withdrawal.
STEP II (A) To be completed by Dean of Students / Registrar  
I HEREBY CERTIFY that has completely withdrawn from classes due to medical reasons for the (fall/winter/spring) semester or term as of Select Date (withdrawal date) and will not receive any academic credit for this semester or term. I also certify that this student will not obtain an incomplete or take make-up examinations resulting in credit for these classes.
Signed: , Dean of Students / Registrar
STEP II (B) To be completed by Business Office  
I HEREBY CERTIFY that (student name), a regularly enrolled student at College/University, has withdrawn for medical reasons, as of
Select Date (withdrawal date).
Please complete the following area based only upon the contracted fees that are insured for the withdrawn semester.
  Insured Semester Costs College will refund/credit under
its own refund schedule
Tuition:  $  $ 
Room, Board and Fees:  $  $ 
Total Tuition, Room, Board and Fees:  $  $ 
Current outstanding balance (if any) on the student's account:  $ 
Signed       Title      
FOR OFFICE USE ONLY
Policy #
INCLUSION DATE CLAIM NO. AMOUNT CODE APR.
         
G42021-A 06/07 (STD)