Class 3 LTD Certificate

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania TABLE OF CONTENTS Page SCHEDULE OF BENEFITS ............................................................................................................................................... 1.0 DEFINITIONS ..................................................................................................................................................................... 2.0 TRANSFER OF INSURANCE COVERAGE ...................................................................................................................... 3.0 GENERAL PROVISIONS ................................................................................................................................................... 4.0 CLAIMS PROVISIONS ....................................................................................................................................................... 5.0 ELIGIBILITY, EFFECTIVE DATE AND TERMINATION .................................................................................................... 6.0 BENEFIT PROVISIONS ..................................................................................................................................................... 7.0 EXCLUSIONS .................................................................................................................................................................... 8.0 LIMITATIONS ..................................................................................................................................................................... 9.0 SPECIFIC INDEMNITY BENEFIT .................................................................................................................................... 10.0 SURVIVOR BENEFIT - LUMP SUM ................................................................................................................................ 11.0 WORK INCENTIVE AND CHILD CARE BENEFITS ........................................................................................................ 12.0 EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ........................................................... 13.0 EXTENDED DISABILITY BENEFIT ................................................................................................................................. 14.0 REHABILITATION BENEFIT ............................................................................................................................................ 15.0 We certify that you (provided you belong to a class described on the Schedule of Benefits) are insured, for the benefits which apply to your class, under Group Policy No. LTD 134339 issued to Goshen Community Schools, the Policyholder. 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 LONG TERM DISABILITY INSURANCE CERTIFICATE CLASS 3 LRS-6570 Ed. 2/83 Ed. 1/2023