Tuition Refund Plan - Notice of Claim

MEDICAL AUTHORIZATION
This part to be completed by guardian or parent
 
Section B
Name of Insured Student
I hereby authorize the release of any medical information necessary to process this claim, and authorize A.W.G. Dewar, Inc. to make refund settlement payable to the School/College named below to be credited to the student's account with any excess to be remitted to me through the School/College.
Date Select Date Authorized Person's Signature
Note:
1. Under the Conditions section of the policy the Company's doctor has the right to examine the student, if necessary.
2. This notice of claim must be submitted to the Company or its representative, A.W.G. Dewar, Inc., within 30 days after the occurrence or commencement of any covered loss.
This part to be completed last by School/College and mailed to A.W.G. Dewar, Inc.
Section C
To: A.W.G. DEWAR, INC., FOUR BATTERYMARCH PARK, QUINCY, MA 02169-7468
We hereby make claim under the Tuition Refund Plan for
                                                                                                                                   (NAME OF STUDENT)
who has been withdrawn from School/College. Date of withdrawal: Select Date through last day of academic year Select Date        -or-
who has been absent from School/College. First date of absense: Select Date through last day of absense Select Date
Grade Level # Day   Boarding Fees Insured: $
 
Our records show absence/withdrawal was due to

(INDICATE TYPE OF INJURY/ILLNESS)
Please complete 1-3 below, only if student has been withdrawn:
1. Unpaid tuition balance, if any $
2. Our records show student attending this School/College the previous academic year (YES/NO)
3. Our records show student has transferred to another school/college (YES/NO);
has become gainfully employed (YES/NO). If "yes" give approximate date Select Date
 
Parent's name & address:
School/College Name:
Signature of School Official:  Title 
Second Signature Required:  Title 
FOR OFFICE USE ONLY
Policy #
INCLUSION DATE CLAIM NO. NET DAYS DIVISOR AMOUNT MAJOR CLASS/FORM CODE APR.
         
 
 
G41604 (03 09)