18-Pay Rate Highlights for Voluntary Accident Insurance

Plan Highlights Voluntary Group Accident Insurance Goshen Community Schools COVERAGE Voluntary accident insurance provides a range of fixed, lump‐sum 18 PAY PREMIUM benefits for injuries resulting from a covered accident, or for Coverage Premium accidental death and dismemberment (if included). These benefits Employee $ 9.70 are paid directly to the insured and may be used for any reason, Employee and Spouse $ 15.21 from deductibles and prescriptions to transportation and Employee & Children $ 15.67 childcare. Employee & Family $ 21.17 ELIGIBILITY FEATURES Each Active Full-Time Employee working 15 hours or more per  Portability to Employee Age 70 week, except for any person working on a temporary or seasonal  FMLA/MSLA Continuation basis.  Newlywed and Newborn Provision Dependents: You must be insured for your Dependents to be  24-Hour Travel Assistance Services covered. Dependents are:  24-Hour Coverage  Your legal spouse or domestic partner. Spouse must be under age 70 at date of application.  Your dependent children from birth to 26 years.  A person may not have coverage as both an Employee and Dependent. BENEFIT AMOUNT See Full Schedule of Benefits on next page BENEFIT REDUCTION DUE TO AGE (Applicable to AD&D coverage only) Age Original Benefit Reduced to 70 50% CONTRIBUTION REQUIREMENTS Coverage is 100% Employee Paid. www.reliancestandard.com This Plan Highlight is not a complete description of the insurance coverage. Insurance is provided under group policy form LRS-9547, et al. This is not a binding contract. Should there be a difference between this Plan Highlight and the contract, the contract will govern. The Certificate of Coverage will be made available to you that describes the benefits in greater detail; however a benefit will not be paid if caused or contributed by an exclusion listed in the Certificate. Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance products and services are provided through First Reliance Standard Life Insurance Company, Home Office: New York, NY. Product features and availability may vary by state.

Benefits Amount Ambulance $200 Ground, $1,000 Air Blood, Plasma and Platelets $300 Burns To $1,600 for 2nd degree burns; To $12,800 for 3rd degree burns; Skin Graft - 50% of benefit payable for Burns Chiropractic Services (per Visit) $50 per session, 6 sessions maximum Coma $7,500 Concussion $200 Dental Injury $300 for Crown; $100 for Extraction Diagnostic Exams $200 per CT/MRI scan Dislocation To $2,800 for Non-surgical; To $5,600 for Surgical; Partial - 37.5% of full dislocation; Multiple - 150% of highest dislocation benefit Emergency Treatment $225 Epidural Anesthesia Injection (per Injection) $200, 2 maximum Eye Injury $150 for removal of foreign object, $300 for surgical repair Fractures To $10,000 for Non-surgical; To $5,000 for Surgical repair; Chip fracture: 37.5% of non- surgical benefit; Multiple fractures: 150% of highest sustained fracture Initial Hospital Admission $1,000 Initial Intensive Care Unit (ICU) Hospital Admission $1,500 Hospital Confinement (per Day) $300, 365 days maximum Intensive Care Unit (ICU) Confinement (per Day) $600, 30 days maximum Lacerations To $800 Lodging (per Day) $150 per day up to 30 days if more than 100 miles from residence Medical Appliances $150 Organized Youth Sports Benefit 5% of the benefit amount Paralysis $15,000 quadriplegia; $7,500 paraplegia/hemiplegia Physical Therapy (per Session) $37.50, 12 sessions maximum Physician Visit $75 Initial, $75 Follow-up Prosthesis $750 for one, $1,500 for two or more Rehabilitation Facility Confinement (per Day) $100, 30 days maximum Surgery $150 for Exploratory; $450 for Knee Cartilage; $1,500 for Abdominal or Thoracic; $750 for Ruptured Disc; to $900 Tendon, Ligament, or Rotator cuff Transportation $450, if more than 100 miles from residence X-Rays $50 Accidental Death Benefits Amount Employee AD&D $50,000 Spouse AD&D $25,000 Child AD&D $10,000 Common Carrier 100% Accidental Dismemberment Benefits % of AD Benefit Amount Single Loss 50% Multiple Loss (Catastrophic) 100% Thumb / Finger / Toe 1% 2+ Thumb / Finger / Toe 3% Speech 100% Wellness (Health Screening) Benefit Amount Wellness (Health Screening) $50 www.reliancestandard.com This Plan Highlight is not a complete description of the insurance coverage. Insurance is provided under group policy form LRS-9547, et al. This is not a binding contract. Should there be a difference between this Plan Highlight and the contract, the contract will govern. The Certificate of Coverage will be made available to you that describes the benefits in greater detail; however a benefit will not be paid if caused or contributed by an exclusion listed in the Certificate. Reliance Standard Life Insurance Company is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. In New York, insurance products and services are provided through First Reliance Standard Life Insurance Company, Home Office: New York, NY. Product features and availability may vary by state.