20-Pay Premium Table Voluntary Life Insurance

Reliance Standard Plans Supplemental and Dependent Life Insurance Premium Table Plan Holder: Goshen Community Schools Scheduled Benefit: Each eligible employee may elect for himself/herself and/or his/her eligible spouse an amount of insurance shown in the table below. For employees age 65 and older: Benefit amounts are reduced according to the age-based reduction chart shown in the Supplemental Life brochure. Employee/Spouse Premiums: To find you and your spouse's premium:  Determine your age band: Your age = your age at your last birthday.  Select a benefit amount (employees age 65 and older: see above comment).  Spouse premium: Repeat the steps above for your spouse at your age at your last birthday.  Employee and spouse rates change as insured moves from one age bracket to the next. Employee 20 Payment Periods Premiums Page 1 of 3

Spouse 20 Payment Periods Premiums Page 2 of 3

Dependent Child(ren) 20 Payment Periods Premiums: Benefit Amount Premium $2,000 $0.31 $4,000 $0.62 $6,000 $0.94 $8,000 $1.25 $10,000 $1.56 (One rate and benefit amount for all eligible children in family, regardless of number) PREMIUM CALCULATION (Add your elections here): Employee Premium Spouse Premium Dependent Child(ren) Premium Total Premium (Rates are calculated as of coverage effective date and are based on insured's age in relation to Plan anniversary date. Billed rates may be higher if, at application, the person is at the highest age in an age band). Please read this important information:  You may not have coverage as both an employee and as a dependent.  Only one insured spouse may cover the eligible dependent children. Rates are subject to change. Page 3 of 3