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Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease at the end of the month of your date of termination. Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalIN.com Contract Start Date: January 1, 2022 Document Creation Date: August 26, 2021 KR#64690433

Delta Dental PPO Plan Benefits Summary for Elkhart Community Schools - Page 3 Delta Dental PPO Plan Benefits Summary for Elkhart Community Schools Page 2