STUDENT MEDICAL REIMBURSEMENT PLAN
SCHEDULE OF INSURED PERSONS

	Please complete and return within 30 days from the opening day of school to: A.W.G. Dewar, Inc., Four Batterymarch Park, Quincy, MA 02169-7468
	Name of School*
	Address*
	City* Select State or Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Yukon    State or Province* Zip Code*
	THE FOLLOWING DETAILS ARE IMPORTANT - PLEASE COMPLETE THIS SECTION
	Classes Commence*	Last Day of Finals*
	Winter Vacation From* To* Spring Vacation From* To*
	Number of Day Students*
	Number of Resident Students*
	Total Enrollment*
	Pre-season Sports Practice Begins*
	*Indicates a required field
	If you would like to attach your complete list of insured students under the Medical Reimbursement Plan, please complete the information above and attach your file with the following information: Insured Persons In Alphabetical Order with Surname First Premium For Each Person The effective date of coverage for an insured person, if in variance with the contract term above specified, is as indicated in the column opposite such person's name. NOTE: USE SHORT SCHEDULE FORM FOR LATE ENTRANTS/ADDITIONS.
	Attach a List of Insured Students
	Attach a Second List of Insured Students (if necessary)