RL-CI4-CERT2-20-IN 3 D12969 (11/25) SCHEDULE OF BENEFITS EMPLOYER: Noblesville Schools GROUP POLICY NUMBER: 73058-1CCI2 ELIGIBLE CLASS(ES) All Eligible Employees, excluding Bus Drivers, working 30 hours or more per week in Active Employment with the Employer in the United States. You must be an Employee of the Employer and in an eligible class. Temporary and seasonal workers are excluded from coverage. Insured Persons who are continuing coverage under the PORTABILITY provision are also an eligible class. ELIGIBILITY WAITING PERIOD Persons in an eligible class on or before the Policy effective date: End of month in which You begin Active Employment. Persons entering an eligible class after the Policy effective date: End of month in which You begin Active Employment. Exception: if you were hired on the first of the month, the waiting period is waived. REHIRE If your employment with the Employer ends and you are rehired within 90 days, your previous Active Employment while in an eligible class will apply toward the Eligibility Waiting Period. All other Policy and Certificate provisions apply. WHO PAYS FOR THE COVERAGE You pay the cost of your coverage. BENEFIT AMOUNT Choice of $5,000 or $10,000 or $15,000 or $20,000 or $25,000 or $30,000