Use for Reporting Adjustments to the Original Schedule.

Attached to and forming part of Policy No.
 Select Date
Date*

Name of School/College*

Address*

City*
State*
Zip Code*
  
Select Date
Classes Commence*		 Select Date
Last Day of Final Exams*
(Exclude Orientation, Registration Days, Early Sports Practice and Graduation.)
*Indicates a required field.
Except where otherwise below specified opposite the name of any student, the insurance hereby provided shall become effective as of the date of the policy to which this schedule is attached.
Student's Name
Arranged Alphabetically
Surname First		 Grade Total
School Fee
Insured		 Premium
Each
Student		 Student's
First Class
Day		 Date Premium Paid
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
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 ONLY if written application is received by the school by the student's first class day.

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