DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE
Tuition Refund Plan
DISMISSAL OR WITHDRAWAL CERTIFICATE
To be completed by the School/College
To:
 		 A.W.G. DEWAR, INC.
FOUR BATTERYMARCH PARK, QUINCY, MA 02169-7468		 Date: Select Date
 

I HEREBY CERTIFY that a regularly enrolled student at School/College was Withdrawn Dismissed and severed his/her connection
as of Select Date


WITHDRAWAL: He/she was withdrawn for the following specific reason:
Has the student completed his/her annual academic requirements? ...................................................................................... YES NO
Will the student receive a certificate of graduation? ......................................................................................................... YES NO

DISMISSAL: He/she was dismissed by the School/College for the following specific reason:
If the incident causing dismissal involved other students, please list the other insured students who were also dismissed on the same date:
The sum of $ has been paid to the School/College on his/her account and under the terms of the enrollment contract there is a balance due the School/College of $
We hereby make claim under Policy No. in respect of the Day Boarding Student
in Grade named above for whom this certificate is submitted. Total fees insured: $
Parent's name (please print)
Parent's address
School/College Name:
Signature of the School Official:  Title 
Second Signature Required:  Title 

Note: This form should be presented to A.W.G. Dewar, Inc. together with the parent's (yellow) Dismissal or
Withdrawal Certificate as soon as possible; in any event, not later than 30 days after date of separation.
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.
FOR OFFICE USE ONLY
INCLUSION DATE CLAIM NO. NET DAYS DIVISOR AMOUNT MAJOR CLASS/FORM CODE APR.
         
 
 
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