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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. Date:

FOUR BATTERYMARCH PARK, QUINCY, MA 02169-7468

WE HEREBY CERTIFY that a regularly enrolled student at

School/College was Withdrawn Dismissed and severed his/her connection as of

(DATE)

We acknowledge that this student has attended at least fourteen consecutive calendar days from the student’s first class day of attendance in

the academic year.

WITHDRAWAL: He/she was withdrawn for the following specific reason: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 School Official: Title

Second Signature Required: Title

PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR IMPORTANT FRAUD

INFORMATION REGARDING YOUR CLAIM.

FOR OFFICE USE ONLY REASON CODE:

INCLUSION DATE

CLAIM NO.

NET DAYS

DIVISOR

AMOUNT

SUBCODE

APR.

G40885 03 1

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.

IMPORTANT NOTICE

To Arizona Claimants

For your protection Arizona law requires the

following statement to appear on this form.

Any person who knowingly presents a false

or fraudulent claim for payment of a loss is

subject to criminal and civil penalties.

TO CLAIMANTS IN ARKANSAS, LOUISIANA,

MARYLAND AND TEXAS,

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT

OR (in AR, LA or MD) KNOWINGLY PRESENTS FALSE

INFORMATION IN AN APPLICATION FOR INSURANCE IS

GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND

CONFINEMENT IN PRISON.

To California Claimants

For your protection California law requires the

following to appear on this form: Any person who

knowingly presents false or fraudulent claim for the

payment of a loss is guilty of a crime and may be

subject to fines and confinement in state prison.

To Colorado Claimants

It is unlawful to knowingly provide false, incomplete, or

misleading facts or information to an insurance

company for the purpose of defrauding or attempting

to defraud the company. Penalties may include

imprisonment, fines, denial of insurance, and civil

damages. Any insurance company or agent of an

insurance company who knowingly provides false,

incomplete, or misleading facts or information to a

policyholder or claimant for the purpose of defrauding

or attempting to defraud the policyholder or claimant

with regard to a settlement or award payable from

insurance proceeds shall be reported to the Colorado

division of insurance within the department of

regulatory agencies.

To Claimants in Delaware, Idaho and Indiana

Any person who knowingly, and with intent to injure, defraud or

deceive any insurer, files a statement of claim containing any false,

incomplete or misleading information is guilty of a felony.

To Florida Claimants

Any person who knowingly and with intent to injure, defraud, or

deceive any insurer, files a statement of claim containing any false,

incomplete, or misleading information is guilty of a felony of the third

degree.

To Kentucky Claimants

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.

To Minnesota Claimants

A person who files a claim with intent to defraud or helps

commit a fraud against an insurer is guilty of a crime.

To New Hampshire Claimants

Any person who, with a purpose to injure, defraud or deceive any

insurance company, files a statement of claim containing any false,

incomplete or misleading information is subject to prosecution and

punishment for insurance fraud, as provided in RSA 638:20.

To New Jersey Claimants

Any person who knowingly files a statement of claim containing any

false or misleading information is subject to criminal and civil

penalties.

TO NEW MEXICO CLAIMANTS

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT

OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND

MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

To New York Claimants

Any person who knowingly and with intent to defraud any insurance

company or other person files an application for insurance or

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, and shall also be subject to a civil penalty not to exceed five

thousand dollars and the stated value of the claim for each such

violation.

To Ohio Claimants

Any person who, with intent to defraud or knowing that he is

facilitating a fraud against an insurer, submits an application or files

a claim containing a false or deceptive statement is guilty of

insurance fraud.

To Oklahoma Claimants

WARNING: Any person who knowingly, and with intent to injure,

defraud or deceive any insurer, makes any claim for the proceeds of

an insurance policy containing any false, incomplete or misleading

information is guilty of a felony.

To Oregon Claimants

Any person who knowingly and with the intent to defraud any

insurer provides false or misleading information concerning any fact

material to a risk to be insured or to a claim for loss or benefits may

be guilty of a crime.

To Pennsylvania Claimants

Any person who knowingly and with intent to defraud any insurance

company or other person files an application for insurance or

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 and subjects such person to criminal and civil penalties.

To Claimants in Virginia, Washington and any

State not listed above

It is a crime to knowingly provide false, incomplete, or misleading

information to an insurance company for the purpose of defrauding

the company. Penalties include imprisonment, fines or a denial of

insurance benefits.

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