APPLICATION FOR TUITION INSURANCE PROPOSAL APPLICATION FOR TUITION INSURANCE PROPOSAL 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 Disciplinary Discharge Months Lost For Entire Student Body Number of Medical Withdrawals Months Lost For Entire Student Body Disease Contamination Withdrawals - Months Lost For Entire Student Body Death of Tuition Payer Months Lost For Entire Student Body Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Loss of Tuition Payer Months Lost For Entire Student Body Voluntary Withdraws Months Lost For Entire Student Body Second Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student Body Disciplinary Discharge Months Lost For Entire Student Body Number of Medical Withdrawals Months Lost For Entire Student Body Disease Contamination Withdrawals - Months Lost For Entire Student Body Death of Tuition Payer Months Lost For Entire Student Body Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Loss of Tuition Payer Months Lost For Entire Student Body Voluntary Withdraws Months Lost For Entire Student Body Third Most Recent Completed School Year:Academic Discharge Months Lost For Entire Student Body Disciplinary Discharge Months Lost For Entire Student Body Number of Medical Withdrawals Months Lost For Entire Student Body Disease Contamination Withdrawals - Months Lost For Entire Student Body Death of Tuition Payer Months Lost For Entire Student Body Job Transfer of Tuition Payer Months Lost For Entire Student Body Job Loss of Tuition Payer Months Lost For Entire Student Body Voluntary Withdraws Months Lost For Entire Student Body Person Completing Application:Name First Last Title Phone*Email* NameThis field is for validation purposes and should be left unchanged. 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