STUDENT MEDICAL REIMBURSEMENT PLAN
SCHEDULE OF LATE APPLICANTS
(Please refer to Instruction Sheet prior to completing this form)

Date: 7/29/2010

POLICY NO.    ISSUED TO
POLICY TERM   DAYS,  FROM TO 

The effective date of coverage for an insured person, if in variance with the policy term above specified, is as indicated in the column opposite such person's name.
INSURED PERSONS - ALPHABETICAL ORDER
(Surnames First)		 PREMIUM Date Premium Payment or Written Application Received by School
Select Date
Select Date
Select Date
Select Date
Select Date
Select Date
Select Date
Select Date
Select Date
Select Date

Note: Additions to the Plan can be made at any time.  Applications received on or after February 1st are entitled to a reduced premium charge (2/3 annual premium for twelve month plan or 1/2 premium if school year plan)

G54065 03 00