APPLICATION FOR TUITION INSURANCE PROPOSAL APPLICATION FOR TUITION INSURANCE PROPOSAL Information About Your SchoolName of Your SchoolAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone NumberType of School Day Boarding Date of Your Classes Opening MM DD YYYY Date of Your Classes Closing MM DD YYYY 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 StudentsNumber of Day StudentsYour 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 RateCurrent 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 StudentAcademic Discharge of StudentDisciplinary Discharge of StudentDeath of Tuition PayerInvoluntary Unemployment of Tuition PayerDisease ContaminationJob Transfer of Tuition PayerVoluntary WithdrawWould 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 contractYour 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 BodyDisciplinary Discharge Months Lost For Entire Student BodyNumber of Medical Withdrawals Months Lost For Entire Student BodyDisease Contamination Withdrawals - Months Lost For Entire Student BodyDeath of Tuition Payer Months Lost For Entire Student BodyJob Transfer of Tuition Payer Months Lost For Entire Student BodyJob Loss of Tuition Payer Months Lost For Entire Student BodyVoluntary Withdraws Months Lost For Entire Student BodySecond Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student BodyDisciplinary Discharge Months Lost For Entire Student BodyNumber of Medical Withdrawals Months Lost For Entire Student BodyDisease Contamination Withdrawals - Months Lost For Entire Student BodyDeath of Tuition Payer Months Lost For Entire Student BodyJob Transfer of Tuition Payer Months Lost For Entire Student BodyJob Loss of Tuition Payer Months Lost For Entire Student BodyVoluntary Withdraws Months Lost For Entire Student BodyThird Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student BodyDisciplinary Discharge Months Lost For Entire Student BodyNumber of Medical Withdrawals Months Lost For Entire Student BodyDisease Contamination Withdrawals - Months Lost For Entire Student BodyDeath of Tuition Payer Months Lost For Entire Student BodyJob Transfer of Tuition Payer Months Lost For Entire Student BodyJob Loss of Tuition Payer Months Lost For Entire Student BodyVoluntary Withdraws Months Lost For Entire Student BodyPerson Completing Application:Name First Last Title This iframe contains the logic required to handle Ajax powered Gravity Forms.
