DELTA DENTAL PLAN OF INDIANA, INC. CONTRACTOR BY: BY: President and CEO (Authorized Signature) (Title) DATE: August 22, 2023 DATE: INPPOCONT1122 i Revised 11/2022 KR#05809057 Delta Dental Contract For The Jay School Corporation This Contract ("Contract") is entered into by and between The Jay School Corporation (the "Contractor") and Delta Dental Plan of Indiana, Inc., an Indiana non-profit corporation ("Delta Dental"). This is a legally binding contract between the Contractor and Delta Dental and is effective on September 1, 2023, the ("Effective Date"). Section I. Declarations The Benefits available are as set forth in this Contract. Delta Dental's liability is limited to the Benefits stated herein; subject to all the terms of this Contract having reference thereto. This Declarations Section and the Summary of Dental Plan Benefits supersedes any contrary provision contained in subsequent sections of this Contract. A. Effective Date: 12:01 A.M. Standard Time, September 1, 2023 B. First Renewal Date: September 1, 2025 C. Client Number: 1157-0001, 0002, 0099 D. Rate(s): Enrollee only - $27.04 per month per Enrollee Enrollee with one or more dependents - $88.31 per month per Enrollee These Rates are contingent upon the enrollment of a minimum of 75 percent of the eligible members of the defined group and their eligible dependents. Rates do not include any applicable claims taxes. These rates assume that claims from nonparticipating dentists will be paid using our national out-of-network fee table.