Fillable Tuition Refund Plan Medical Withdrawal/Absence Notice of Claim

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Tuition Refund Plan Medical Withdrawal/Absence Notice of Claim

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Tuition Refund Plan Medical Withdrawal/Absence Notice of Claim
Name of Insured Student: ___________________________________________ School Name: __________________________________
I HEREBY AUTHORIZE the physician to complete the Attending Physician’s Statement and to release this and other information to
A.W.G. Dewar, Inc. for their use in documentation of claim for recovery from the insurance contract currently in effect. I also authorize
A.W.G. Dewar, Inc. to make refund settlement payable to the School/College for credit to the student’s account.
Date _____________________ Authorized Person’s Signature ___________________________________________________________
(Parent, legal guardian, or student if legal age)
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR IMPORTANT FRAUD INFORMATION REGARDING YOUR CLAIM.
This notice of claim must be submitted to the Company or its representative, A.W.G. Dewar, Inc.,
within 30 days after the occurrence or commencement of any covered loss.
To: A.W.G. DEWAR, INC., FOUR BATTERYMARCH PARK, QUINCY, MA 02169-7468
Section A
ATTENDING PHYSICIAN’S STATEMENT
This part of claim form to be completed by physician’s office.
Your answers to the questions below should clearly establish the medical necessity for absence or withdrawal.
I HEREBY CERTIFY THAT _________________________________ , a student at ____________________________________________,
(NAME) (SCHOOL/COLLEGE)
has been a patient under my care and has withdrawn from school due to the following medical condition(s):
__________________________________________________________________________________________________________________
(DIAGNOSIS)
ICD Code # _________________________________________ or DSM Code # _________________________________________________
The student has been unable to attend class from _______________________, 20 ______ through _________________________, 20 _______
Date first consulted for this condition ________________, 20 ____ Date last consulted for this condition ___________________, 20 _______
Number of professional visits for this condition: Home _________ Office ___________ Hospital _________
1. Is student still under your care for the above condition? _________________________________________________________ (YES/NO)
2. If referred to another physician, please give the name and address: ___________________________________________________________
_________________________________________________________________________________________________________________
If student referred to you by another physician, please give the name and address: _______________________________________________
_________________________________________________________________________________________________________________
3. In your opinion, did this condition have its inception prior to August 1st last? ________ (YES/NO) If “yes”, please complete (a) & (b):
(a) Did the student receive treatment for this condition between February 1 – August 1 last? _________ (YES/NO)
(b) Please provide dates of any treatment prior to August 1st last: ___________________________________________________________
4. Has this student been withdrawn on your recommendation from classes for the rest of the current academic year? __________ (YES/NO)
Please give reason for recommending or not recommending withdrawal:_______________________________________________________
_________________________________________________________________________________________________________________
5. When do you anticipate student will be able to resume classes at the above-mentioned School/College? ______________________________
6. Is student now attending or planning to enroll in another school/college (or become gainfully employed) during period of withdrawal from
above-mentioned School/College? _______________ (YES/NO) If “yes”, is this with your permission? _____________ (YES/NO)
Give approximate date ___________ __________________________________________________________________________________
(PLEASE EXPLAIN)
7. Has the absence/withdrawal of this student resulted from the use of drugs or narcotics not authorized by a physician? ________ (YES/NO)
Signature of physician __________________________________________________________M.D. Date ____________________________
Please print name: ________________________________________________________ Physician License # _________________________
Please print address: _____________________________________________________________Telephone #__________________________
G41604-B 03 12
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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Tuition Refund Plan Medical WithdrawalAbsence Notice of Claim

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Completed 21 September 2021

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