Accidental Death and Dismemberment (AD&D) Insurance Summary

Offered by Life Insurance Company of North America Employer-Paid ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Summary of Benefits Prepared for: Elkhart Community Schools Eligibility: All active Employees of the Employer classified as Certified, regularly working a minimum of 20 hours per week in the United States, who are citizens or permanent resident aliens of the United States, excluding Employees classified as Custodian. Employee:You will be eligible for coverage the first of the month following date of hire. AvailableCoverage: Benefit Amount Maximum Employee $50,000 $50,000 Benefit Details: If, within 365 days of a Covered Accident, bodily injuries result in: We’ll pay this % of the Benefit Amount: Loss of life; Quadriplegia; Loss of two or more hands or feet; Loss of sight in both eyes; or Loss of 100% speech and hearing (both ears) Paraplegia 75% Hemiplegia; Loss of one hand, one foot, sight in one eye, speech, or hearing in both ears; or 50% Severance and Reattachment of one hand or foot Uniplegia; Loss of all four fingers of the same hand; or Loss of thumb and index finger of the same 25% hand Loss of all toes of the same foot 20% For Comas – You will receive 1% of the full benefit amount each month, for up to a maximum of 11 months , if you or an insured family member are in a coma for 30 days or more as a result of a Covered Accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. Additional Features: For Wearing a Seatbelt & Protection by an Airbag – You will receive an additional 10% benefit but not more than $5,000 if the covered person dies in a covered automobile accident and law enforcement-certified to be wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $2,500 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Exposure & Disappearance – Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a Covered Accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a Covered Accident. For a Loss Resulting from a Common Carrier – If you or an insured family member suffer a covered loss while riding as a passenger in, or being struck by, a common carrier, we will pay an additional 100% of the benefit amount, to a maximum of $50,000. Conversion – If group accident coverage ends (except due to nonpayment of premium), your employment is terminated, membership in an eligible class is terminated, or insurance coverage is reduced based on attained age, you can convert to an individual non-term policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Dependents may convert their coverage as well if applicable. Premiums may change at this time, and terms of coverage will be subject to change. You can also convert to an individual policy of up to $10,000 if you have been insured for at least 5 years and the policy is terminated or amended, provided coverage is not replaced and you are not covered under a different conversion policy issued by Life Insurance Company of North America. Refer to your certificate for details. Important Definitions and Policy Provisions: When your coverage begins - Coverage begins on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form if applicable, or the date you authorize any necessary payroll deductions if applicable. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage, if applicable, will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. When your coverage ends - Coverage ends on the earliest of the date you or your dependents , if applicable, are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. (Under certain circumstances, your coverage may be continued if you stop working. Be sure to read the Continuation of Insurance provisions in your Certificate.)

Benefit Reductions, Exclusions and Limitations Exclusions - Self-inflicted injuries or suicide while sane or insane • commission or attempt to commit a felony or an assault • any act of war, declared or undeclared • any active participation in a riot, insurrection or terrorist act • bungee jumping • parachuting • skydiving • parasailing • hang- gliding • sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food• voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed • operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it • a Covered Accident that occurs while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days) • traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates • air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent • flight in, boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface being flown by the covered person or in which the covered person is a member of the crew. Limitations – For multiple covered losses, benefits are paid for the single largest benefit available. For loss of life, the benefit amount shown will be reduced by the amount of any dismemberment benefits that were previously paid or payable. THIS POLICY PROVIDES LIMITED ACCIDENT-ONLY COVERAGE. IT PAYS A FIXED BENEFIT AND DOES NOT COVER MEDICAL EXPENSES AS INCURRED. IT DOES NOT COVER LOSSES CAUSED BY SICKNESS. THIS IS NOT A SUBSTITUTE FOR COMPREHENSIVE OR MAJOR MEDICAL HEALTH INSURANCE. Terms and conditions of coverage for Accidental Death and Dismemberment insurance are set forth in Group Policy No. OK 968926. This is not intended as a complete description of the insurance coverage offered. This is not a contract. Complete coverage details, including premiums, eligible injuries, their respective payments and policy exclusions and limitations are contained in the Policy Certificate. If there are any differences between this summary and the group policy, the information in the group policy takes precedence. Product availability and/or features may vary by state. Please keep this material as a reference. Insurance coverage is issued on group policy form number: Policy Form TL-004700. Coverage is underwritten by Life Insurance Company of North America, 51 Madison Avenue New York, NY 10010. Group insurance products are insured by Life Insurance Company of North America and New York Life Group Insurance Company of NY, affiliates of New York Life Insurance Company. ©2022New York Life Group Insurance Company, New York, NY. All Rights Reserved. NEW YORK LIFE and the New York Life box logo are trademarks of New York Life Insurance Company. Created on 02/2022.