RL-HI2-CERT-20-IN 3 D12970 (11/25) SCHEDULE OF BENEFITS EMPLOYER: Noblesville Schools GROUP POLICY NUMBER: 73058-1CHI2 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. 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 provisions apply. WHO PAYS FOR THE COVERAGE You pay the cost of your coverage. BENEFIT AMOUNTS DAILY CONFINEMENT AMOUNT(S) $250 CONFINEMENT DAILY BENEFITS Facility Confinement Benefits Hospital Confinement 1 times the daily Confinement amount per day, up to a maximum of 90 days per Confinement Critical Care Unit (CCU) Confinement 1 times the daily Confinement amount per day, up to a maximum of 15 days per Confinement Admission Benefits Hospital Admission $1,000 for the first day of Hospital Confinement, once per Confinement Only one type of facility Confinement or admission benefit is payable per day. Each type of admission benefit is payable 8 times per calendar year. Any combination of facility Confinement and admission benefits payable will not exceed a total of 106 days during a period of Confinement.