Class 1 Group Life (Basic and Term) Certificate

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania TABLE OF CONTENTS Page SCHEDULE OF BENEFITS ............................................................................................................................................... 1.0 DEFINITIONS ..................................................................................................................................................................... 2.0 GENERAL PROVISIONS ................................................................................................................................................... 3.0 LIMITATIONS ..................................................................................................................................................................... 4.0 EFFECTIVE DATE AND TERMINATION .......................................................................................................................... 5.0 CONVERSION PRIVILEGE ............................................................................................................................................... 6.0 BENEFICIARY AND FACILITY OF PAYMENT ................................................................................................................. 7.0 SETTLEMENT OPTIONS .................................................................................................................................................. 8.0 WAIVER OF PREMIUM IN EVENT OF TOTAL DISABILITY ............................................................................................ 9.0 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE ...................................................................................... 10.0 TOTAL LOSS OF USE ..................................................................................................................................................... 11.0 SEAT BELT AND AIR BAG BENEFIT ............................................................................................................................. 12.0 CLAIMS PROVISIONS ..................................................................................................................................................... 13.0 DEPENDENT LIFE INSURANCE .................................................................................................................................... 14.0 EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ........................................................... 15.0 PORTABILITY .................................................................................................................................................................. 16.0 GROUP TERM LIFE INSURANCE ACCELERATED BENEFIT RIDER .......................................................................... 17.0 ACCELERATED BENEFIT RIDER DISCLOSURE .......................................................................................................... 18.0 CERTIFICATE OF INSURANCE We certify that you (provided you belong to a class described on the Schedule of Benefits and your completed enrollment card is attached) are insured, for the benefits which apply to your class, under Group Policy No. GL 166285 issued to Goshen Community Schools, the Policyholder. When loss of life covered under the Policy occurs, we will pay the amount stated on the Schedule of Benefits to the named beneficiary, subject to provisions entitled Beneficiary and Facility of Payment. This Certificate is not a contract of insurance. It contains only the major terms of insurance coverage and payment of benefits under the Policy. It replaces all certificates that may have been issued to you earlier. Secretary President GROUP LIFE INSURANCE CERTIFICATE LRS-6423 Ed. 11/84 CLASS 1 Ed. 2/2023