APPLICATION FOR TUITION INSURANCE PROPOSAL APPLICATION FOR TUITION INSURANCE PROPOSAL "*" indicates required fields Information About Your SchoolName of Your School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberType of School Day Boarding Date of Your Classes Opening Month Day Year Date of Your Classes Closing Month Day Year Applicable Tuition/Fees:Avg. Annual Tuition/Fees Per Student: Total Tuition/Fees Collected From The Entire Student Body: do not include financial aidNumber of Students:Pre-K-K Enrollment1-8 Enrollment9-12 EnrollmentNumber of Students on installment payment plansNumber of Boarding Students Number of Day Students Your Tuition Refund Practices:Do you have a written procedure to handle tuition refunds? Yes No What is your current tuition Insurance plan design? Voluntary Mandatory For Installment Payers Mandatory for All Students Current Tuition Rate Current Participation(no. of students) Desired Coverages. The following causes of loss may be covered. Indicate a percentage of payment (from 0% to 100%):Medical Withdrawal of Student Academic Discharge of Student Disciplinary Discharge of Student Death of Tuition Payer Involuntary Unemployment of Tuition Payer Disease Contamination Job Transfer of Tuition Payer Voluntary Withdraw Would you like to include tuition continuance coverage. This coverage allows for a student to have an approved claim paid for the death of a tuition payer or job loss of a tuition payer without having to withdraw from school. Without this endorsement a student has to withdraw from school for coverage to potentially apply.Would you like to include tuition continuance coverage. This coverage allows for a student to have an approved claim paid for the death of a tuition payer or job loss of a tuition payer without having to withdraw from school. Without this endorsement a student has to withdraw from school for coverage to potentially apply. Yes, I would like continuance coverage. No, I would not like continuance coverage. Supplemental Information:*specimen of your current enrollment contractMax. file size: 100 MB.Your Discharge and Withdrawal History (by Academic Year)- MONTHS LOST FOR ALL STUDENTS ENROLLED IN THE SCHOOLMost Recent Completed School Year:do not use current school year if it is in progressAcademic Discharge Months Lost For Entire Student Body Academic Discharge Total Students Withdrawn Disciplinary Discharge Months Lost For Entire Student Body Disciplinary Discharge Total Students Withdrawn Number of Medical Withdrawals Months Lost For Entire Student Body Medical Withdrawals Total Students Withdrawn Disease Contamination Withdrawals - Months Lost For Entire Student Body Disease Contamination Total Students Withdrawn Death of Tuition Payer Months Lost For Entire Student Body Death of Tuition Payer Total Students Withdrawn Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Transfer Total Students Withdrawn Job Loss of Tuition Payer Months Lost For Entire Student Body Job Loss Total Students Withdrawn Voluntary Withdrawals Months Lost For Entire Student Body Voluntary Withdrawals Total Students Withdrawn Second Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student Body Academic Discharge Total Students Withdrawn Disciplinary Discharge Months Lost For Entire Student Body Disciplinary Discharge Total Students Withdrawn Number of Medical Withdrawals Months Lost For Entire Student Body Medical Withdrawals Total Students Withdrawn Disease Contamination Withdrawals - Months Lost For Entire Student Body Disease Contamination Total Students Withdrawn Death of Tuition Payer Months Lost For Entire Student Body Death of Tuition Payer Total Students Withdrawn Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Transfer Total Students Withdrawn Job Loss of Tuition Payer Months Lost For Entire Student Body Job Loss Total Students Withdrawn Voluntary Withdraws Months Lost For Entire Student Body Voluntary Withdrawals Total Students Withdrawn Third Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student Body Academic Discharge Total Students Withdrawn Disciplinary Discharge Months Lost For Entire Student Body Disciplinary Discharge Total Students Withdrawn Number of Medical Withdrawals Months Lost For Entire Student Body Medical Withdrawals Total Students Withdrawn Disease Contamination Withdrawals - Months Lost For Entire Student Body Disease Contamination Total Students Withdrawn Death of Tuition Payer Months Lost For Entire Student Body Death of Tuition Payer Total Students Withdrawn Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Transfer Total Students Withdrawn Job Loss of Tuition Payer Months Lost For Entire Student Body Job Loss Total Students Withdrawn Voluntary Withdraws Months Lost For Entire Student Body Voluntary Withdrawals Total Students Withdrawn Person Completing Application:Name First Last Title Phone*Email* Captcha (required to eliminate spam)*What does 4 + 6 equal?NameThis field is for validation purposes and should be left unchanged. 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