Tuition Protector Underwriting Information Section 1: School Information Name of School Address City, State and Zip Mailing Address Mailing City/State/Zip Phone xxx-xxx-xxxx Fax xxx-xxx-xxxx E-mail Classes Open January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009 2010 2011 2012 Classes Close January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009 2010 2011 2012 TUITION/FEES: In-State Out of State Tuition Room & Board Fees Total Student Population:  Male: % Female: % Section 2: Current Tuition Refund Procedure How do you currently handle refunds of tuition? Written procedure in place that is followed * Compulsory tuition refund insurance policy * Voluntary tuition refund insurance policy * Indicate insurance company name Other Procedure Section 3: Plan Desired Check the perils that you are interested in Medical Widthdrawl Disciplinary Dismissal Job Transfer of Tuition Payer Epidemic Closure Death of Student Voluntary Withdrawl Academic Dismissal Involuntary Unemployment of Tuition Payer Death of Tuition Payer Section 4: Attachments Current Enrollment Contract Tuition Bill Form Current Tuition Refund Program Policy or Rules Section 5: Confidential Dismissal/Withdrawl Record Note: Exclude dismissals/withdrawls during the first 14 days of class attendance. INCLUDE all medical withdrawls 5 Academic Years Current Year Prior Year Prior Year Prior Year Prior Year DISMISSALS Academic Disciplinary Total Total Months Lost MEDICAL WITHDRAWLS # of Withdrawls Total Months Lost NON-MEDICAL WITHDRAWLS Voluntary Job Transfer of Tuition Payer Involuntary Unemployment Death of Tuition Payer Total Total Monthls Lost Name of Person Requesting Proposal: Title: Phone: Fax: Site and Contents (c) NorthStar | Disclaimer & Legal Notices Site Design By Johnson Technical Group, Inc.