Fidelity Security Life Insurance Company Group Vision Insurance Policy

F I D E L I T Y S E C U R I T Y L I F E ® I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) POLICY NUMBER: VC-146 POLICYHOLDER: Jay School Corporation STATE OF ISSUE: Indiana POLICY EFFECTIVE DATE: September 1, 2022 POLICY ANNIVERSARY DATE: September 1 of the following year and each September 1 thereafter Fidelity Security Life Insurance Company agrees to pay the benefits provided by the Policy in accordance with its terms and conditions. The Policy is issued in consideration of the Policyholder’s application (a copy of which is attached) and receipt by the Company of the premiums. All periods of time under the Policy begin and end at 12:01 A.M. Local Time at the Policyholder’s business address. The Policy may be modified by mutual agreement between the Policyholder and the Company. The Policy is issued by Fidelity Security Life Insurance Company at Kansas City, Missouri on the Policy Effective Date. FIDELITY SECURITY LIFE INSURANCE COMPANY President Secretary GROUP VISION INSURANCE POLICY THIS IS A LIMITED BENEFIT POLICY Please read the Policy carefully. M-9184

PREMIUMS Premiums are payable in advance by the Policyholder. The first premium is due on the effective date of the Policy. Subsequent premiums are due on the first day of each calendar month thereafter. The required premium due on each premium due date is the sum of the premiums for all Insureds and their Dependents covered under the Policy. The premiums due will be determined by applying the premium rates then in effect for each plan provided by the Policy to the number of Insured Persons. All premiums are payable to the Company at the Company’s home office or to any of the Company’s authorized agents. The premium due may be adjusted due to a change in insurance as requested by the Policyholder or as required by the Company as follows: 1. if an amount of insurance is added or increased during a calendar month, premiums will be increased as of the date the change becomes effective, unless otherwise mutually agreed; 2. if an amount of insurance is deleted or decreased during a calendar month, premium will cease or be decreased at the end of the calendar month in which the deletion or decrease occurred, unless otherwise mutually agreed; 3. if the Policyholder’s contribution percentage is changed, premium will be adjusted at the end of the calendar month in which the change occurred, unless otherwise mutually agreed; or 4. if the number of eligible employees increases or decreases by more than 10% premium will be adjusted at the end of the calendar month in which the increase or decrease occurred, unless otherwise mutually agreed. If premiums are due the Company or premium refunds are due the Policyholder as a result of clerical error or delay in the reporting of dates and/or data to the Company, all premiums or refunds will be calculated at the current rate of premium payment and are limited to a maximum period of the current month plus six months. Premium Rate Change. The Company has the right to change the premium rate on or after the fourth Policy Anniversary Date. The Company will provide written notice at least 31 days before the date of change. Grace Period. A grace period of 31 days will be allowed to the Policyholder for the payment of each premium due after the first premium. The Policy will remain in force during the grace period. If the required premium is not paid by the end of the 31-day period, the Policy will terminate. The Policyholder will be required to pay premium for the grace period. Return of Premium. The Company reserves the right to rescind the coverage for one or all Insureds due to misrepresentation or fraud on the Policyholder’s application or an Insured’s enrollment form, if such misrepresentation materially affected the acceptance of the risk. If, on the date coverage is rescinded, no claims have been paid under the Policy, the Company will return all premiums paid for such coverage to the Policyholder. If, on the date coverage is rescinded, claims have been paid under the Policy, the Company reserves the right to deduct from the premiums to be returned to the Policyholder an amount equal to the amount of such claims paid. TERMINATION OF POLICY The Policyholder or the Company may terminate or cancel the Policy on the earliest of the following: 1. any date on or after the fourth Policy Anniversary Date the Company requests termination. Written notice must be provided to the Policyholder at least 31 days prior to termination; 2. any date on or after the date the Company receives the Policyholder’s written request for termination; 3. the date the number of persons covered under the Policy does not meet the minimum participation requirements of 10; 4. the date the required premium has not been paid, except as provided in the Grace Period provision; or 5. the date 100% of the eligible employees are not covered when a contribution is not required by the employee. M-9184 2

The Policyholder is responsible for notifying the Insured of the termination of the Policy. Termination of the insurance of any Insured Person will be without prejudice to any claim originating before the date of termination. CERTIFICATE The Company will furnish the Certificate to the Policyholder for the Insured which will set forth the essential features of the insurance coverage. ADDITIONAL INSUREDS Insured Persons may be added at any time if they meet the eligibility requirements stated in the Policyholder’s application, complete an enrollment form, if required, and pay any required premium. INCORPORATION PROVISION The provisions of the attached Certificate and all Rider(s) issued with the Policy or to amend the Policy after the Policy Effective Date are made a part of the Policy. M-9184 3

F I D E L I T Y S E C U R I T Y L I F E ® I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) POLICY NUMBER: VC-146 POLICYHOLDER: Jay School Corporation POLICY EFFECTIVE DATE: September 1, 2022 POLICY ANNIVERSARY DATE: September 1 of the following year and each September 1 thereafter Fidelity Security Life Insurance Company represents that the Insured Person is insured for the benefits described in the following pages, subject to and in accordance with the terms and conditions of the Policy. The Policy may be amended, changed, cancelled or discontinued without the consent of any Insured Person. The Certificate explains the plan of insurance. An individual identification card will be issued to the Insured containing the group name, group number, and Insured’s effective date. The Certificate replaces all certificates previously issued to the Insured under the Policy. All periods of time under the Policy will begin and end at 12:01 A.M. Local Time at the Policyholder’s business address. The Policy is issued by Fidelity Security Life Insurance Company at Kansas City, Missouri on the Policy Effective Date. FIDELITY SECURITY LIFE INSURANCE COMPANY President Secretary GROUP VISION INSURANCE CERTIFICATE THIS IS A LIMITED BENEFIT CERTIFICATE Please read the Certificate carefully. THIS PLAN IS NOT MEDICARE SUPPLEMENT. If you are eligible for Medicare, please review “Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare,” available from the Company. C-9184IN Exam/Materials

TABLE OF CONTENTS DEFINITIONS ........................................................................................................................................................................ 3 EFFECTIVE DATES .............................................................................................................................................................. 4 BENEFITS .............................................................................................................................................................................. 5 LIMITATIONS ....................................................................................................................................................................... 5 EXCLUSIONS ........................................................................................................................................................................ 5 TERMINATION OF INSURANCE ....................................................................................................................................... 6 PREMIUMS ............................................................................................................................................................................ 6 CLAIMS ................................................................................................................................................................................. 7 GENERAL PROVISIONS ..................................................................................................................................................... 8 SCHEDULE OF BENEFITS ............................................................................................................................. Attached (1A) C-9184IN 2

DEFINITIONS Allowance means the benefit amount shown in the Schedule of Benefits that is the maximum amount payable by the Company, subject to the expenses incurred. The Insured Person is responsible for any amounts due above the Allowance. The Allowance cannot be used to satisfy a Copayment. Benefit Frequency means the period of time in which a benefit is payable as shown in the Schedule of Benefits. The Benefit Frequency begins on September 1. Each new Benefit Frequency begins at the expiration of the previous Benefit Frequency. Copayment or Copay means the designated amount, if any, shown in the Schedule of Benefits each Insured Person must pay to a Provider before benefits are payable for a covered Vision Examination or Vision Materials per Benefit Frequency. Comprehensive Eye Examination means a general evaluation of the complete visual system. The examination includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, basic sensorimotor examination and Refraction. It always includes initiation of diagnostic and treatment programs. It may include biomicroscopy, examination with cycloplegia or mydriasis and tonometry, as determined by the Provider. These services may be performed at different sessions, but comprise only one Comprehensive Eye Examination. Dependent means any of the following persons whose coverage under the Policy is in force and has not ended: 1. the Insured’s lawful spouse; 2. each child of the Insured or the Insured’s spouse who is under 26 years of age; or 3. each child at least 26 years of age who is primarily dependent upon the Insured or the Insured’s spouse for support and maintenance because the child is incapable of self-sustaining employment by reason of mental incapacity or physical handicap. Dependent includes a step-child, foster child, legally adopted child, child for whom the Insured is a party to a suit for adoption, child who has been placed in the Insured’s home for adoption and child under the Insured’s legal guardianship. Dependent will also include a child for whom the Insured is legally required to support due to court order or divorce decree. Formulary means a list, provided by the Company, of Vision Materials by tier, that are covered under the Policy as shown in the Schedule of Benefits. Insured means an employee of the Policyholder who meets the eligibility requirements as shown in the Policyholder’s application, and whose coverage under the Policy is in force and has not ended. Insured Person means the Insured. Insured Person will also include the Insured’s Dependents, if enrolled. In-Network Provider means a Provider who has signed a Preferred Provider Agreement with the PPO. Medically Necessary Contact Lenses means that adequate functional vision correction cannot be achieved with spectacles but can be achieved with contact lenses. Conditions that qualify for Medically Necessary Contact Lenses are: 1. Anisometropia of 3D in meridian powers; 2. High Ametropia exceeding -12D or +12D in meridian powers; 3. Keratoconus when vision is not correctable to 20/25 in either eye or both eyes using standard spectacle lenses; or 4. vision impairments, other than Keratoconus, when vision can be improved by two lines on the visual acuity chart when compared to best corrected standard spectacle lenses. Out-of-Network Provider means a Provider, located within the PPO Service Area, but is not an In-Network Provider. Policy means the Vision Insurance Policy issued to the Policyholder. C-9184IN 3

Policyholder means the employer named as the Policyholder in the face page of the Policy. PPO Service Area means the geographical area where the PPO is located. Preferred Provider Agreement means the agreement between the PPO and a Provider who agrees to become an In-Network Provider. The Preferred Provider Agreement contains the rates and reimbursement methods for services and supplies furnished by an In-Network Provider. Preferred Provider Organization (“PPO”) means a network of Providers and retail chain stores within the PPO Service Area that have signed a Preferred Provider Agreement. Provider means a licensed physician or optometrist who is operating within the scope of his or her license. Provider also includes a dispensing optician. Refraction means a test performed by a Provider to determine the glasses or contact lens prescription due to a refractive error (for example, nearsightedness, farsightedness, astigmatism or presbyopia). Vision Examination means any eye or visual examination covered under the Policy and shown in the Schedule of Benefits. Vision Materials means those materials provided for visual health and welfare shown in the Schedule of Benefits. EFFECTIVE DATES Effective Date of Insured’s Insurance. The Insured’s insurance will be effective as follows: 1. if the Policyholder does not require the Insured to contribute toward the premium for this coverage, the Insured’s insurance will be effective on the date the Insured becomes eligible; 2. if the Policyholder requires the Insured to contribute toward the premium for this coverage, the Insured’s insurance will be effective on the date the Insured becomes eligible, provided; a. the Insured has given the Company the Insured’s enrollment form (if required) on, prior to, or within 30 days of the date the Insured becomes eligible; and b. the Insured has agreed to pay the required premium contributions; and 3. if the Insured fails to meet the requirements of 2 a) and 2 b) within 30 days after becoming eligible, the Insured’s coverage will not become effective until the Company has verified that the Insured has met these requirements. The Insured will then be advised of the Insured’s effective date. Effective Date of Dependents’ Insurance. Coverage for Dependents becomes effective on the later of: 1. the date Dependent coverage is first included in the Insured’s coverage; or 2. the premium due date on or after the date the person first qualifies as the Insured’s Dependent. If an enrollment form is required, the Insured must provide such form and agree to pay any premium contribution that may be required prior to coverage becoming effective. If the Insured and the Insured’s spouse are both Insureds, one Insured may request to be a Dependent spouse of the other. A Dependent child may not be covered by more than one Insured. Newborn Children. A Dependent child born while the Insured’s coverage is in force will be covered from the moment of birth for 31 days or a greater number of days, if elected by the Policyholder. To continue coverage beyond this period, the Insured must provide notice to the Company and agree to pay any premium contribution that may be required within this period. Adopted Children. If a Dependent child is placed with the Insured for adoption while the Insured’s coverage is in force, this child will be covered from the earlier of: 1) the date of placement for the purpose of adoption; or 2) the date of the entry of an order granting the Insured custody of the child for purposes of adoption for 31 days or a greater number of days, if C-9184IN 4

elected by the Policyholder. To continue coverage beyond this period, the Insured must provide notice to the Company and agree to pay any premium contribution that may be required within this period. If proper notice has been given, coverage will continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. BENEFITS Benefits are payable for each Insured Person as shown in the Schedule of Benefits for expenses incurred while this insurance is in force. In-Network Provider Benefits. The Insured Person must pay any Copayment or any cost above the Allowance shown in the Schedule of Benefits at the time the covered service is provided. Benefits will be paid to the In-Network Provider who will file a claim with the Company on behalf of the Insured Person. Out-of-Network Provider Benefits. The Insured Person must pay the Out-of-Network Provider the full cost at the time the covered service is provided and file a claim with the Company, unless the Out-of-Network Provider allows assignment of benefits. The Company will pay the Out-of-Network benefits up to the maximum dollar amount shown in the Schedule of Benefits. LIMITATIONS Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. EXCLUSIONS No benefits will be paid for services or materials connected with or charges arising from: 1. medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; 2. Refraction, when not provided as part of a Comprehensive Eye Examination; 3. services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 4. orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 5. any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; 6. safety eyewear; 7. solutions, cleaning products or frame cases; 8. non-prescription sunglasses; 9. plano (non-prescription) lenses; 10. plano (non-prescription) contact lenses; 11. two pair of glasses in lieu of bifocals; 12. electronic vision devices; 13. services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or 14. lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. C-9184IN 5

TERMINATION OF INSURANCE The Policyholder or the Company may terminate or cancel the Policy as shown in the Policy. For All Insureds. The Insureds’ insurance will cease on the earlier of: 1. the date the Policy ends; 2. the end of the last period for which any required premium contribution agreed to in writing has been made; 3. the date the Insured is no longer eligible for insurance; or 4. the date the Insured’s employment with the Policyholder ends. The Policyholder may, at the Policyholder’s option, continue insurance for individuals whose employment has ended, if the Policyholder: a. does so without individual selection between Insureds; and b. continues to pay any premium contribution for those individuals. For Dependents. A Dependent’s insurance will cease on the earlier of: 1. the date the Insured’s coverage ends; 2. the end of the year in which the Dependent ceases to be an eligible Dependent as defined in the Policyholder’s application; or 3. the end of the last period for which any required premium contribution has been made. A Dependent child will not cease to be a Dependent solely because of age if the child is: 1. not capable of self-sustaining employment due to mental incapacity or physical handicap that began before the age limit was reached; and 2. mainly dependent on the Insured for support. The Company may ask for proof of the eligible Dependent child’s incapacity and dependency 120 days prior to the date the Dependent child would otherwise cease to be covered. The Company may require the same proof again, but will not request it more than once a year after this coverage has been continued for two years. This continued coverage will end on the earlier of: 1. on the date the Policy ends; 2. on the date the incapacity or dependency ends; 3. on the end of the last period for which any required premium contribution for the Dependent child has been made; or 4. 60 days following the date the Company requests proof and such proof is not provided to the Company. PREMIUMS The Company provides insurance coverage in return for premium payment. Premiums are payable to the Company by the Policyholder on behalf of the Insured Person. The Insured Person’s first premium is due on the Insured Person’s Effective Date. Premiums must be paid to the Company on or before the due date. The initial premium rates are shown in the Policyholder’s application. Premium Changes. The Company has the right to change the premium rates on any premium due date as allowed in the Policy. The Company will provide written notice to the Policyholder at least 31 days before the date of the change. The premium rates also may be changed at any time the terms of the Policy are changed. Grace Period. The Policy has a 31-day grace period for the payment of each premium due after the first premium. Coverage will continue in force during the grace period. Coverage will terminate at the end of the grace period if all premiums due are not paid. The Company will require payment of all premiums for the period this coverage continues in force, including the premiums for the grace period. The grace period will not apply if the Company receives written notice of the Policyholder’s or the Insured’s intent to terminate coverage. C-9184IN 6

Unpaid Premium. When a claim is paid during the grace period, any premium due and unpaid for the Insured Person will be deducted from the claim payment. CLAIMS Notice of Claim. Written notice of claim must be given to the Company within 30 days after the occurrence or commencement of any loss covered by the Policy, or as soon as is reasonably possible. Notice given by or for the Insured Person to the Company at the Company’s home office, to the Company’s authorized administrator or to any of the Company’s authorized agents with sufficient information to identify the Insured Person will be deemed as notice to the Company. Claim Forms. The Company will furnish claim forms to the Insured Person within 15 days after notice of claim is received. If the Company does not provide the forms within that time, the Insured Person may send written proof of the occurrence, character and extent of loss for which the claim is made within the time stated in the Policy for filing proof of loss. Proof of Loss. Written proof of loss must be furnished to the Company at the Company’s home office within 90 days after the date of the loss. Failure to furnish proof within the time required will not invalidate or reduce any claim if it was not reasonably possible to give proof within that time, if the proof is furnished as soon as reasonably possible. In no event, except in the absence of legal capacity, will proof of loss be accepted later than one year from the time proof is required. Time Payment of Claims. Any benefit payable under the Policy will be paid not more than 45 days, after receipt of due written proof of loss for a Clean Claim. If the Company fails to pay or denies a Clean Claim within the 45 days and the Company subsequently pays the claim, the Company will pay interest on the amount of the claim. Interest paid accrues beginning 46 days after the date the claim is filed and will stop accruing on the date the claim is paid. If the claim is filed electronically, any benefit payable under the Policy will be paid not more than 30 days after receipt of due written proof of loss for a Clean Claim. If the Company fails to pay or denies a Clean Claim within the 30 days and the Company subsequently pays the claim, the Company will pay interest on the amount of the claim. Interest paid accrues beginning 31 days after the date the claim is filed and will stop accruing on the date the claim is paid. A “Clean Claim” means a claim submitted for payment that has no defect, impropriety or particular circumstance requiring special treatment preventing payment. Payment of Claims. All claims will be paid to the Insured, unless assigned. Any benefits payable on or after the Insured’s death will be paid to the Insured’s estate. Assignment. Benefits under the Policy may be assigned. Right of Recovery. If payment for claims exceeds the amount for which the Insured Person is eligible under any benefit provision or rider of the Policy, the Company has the right to recover the excess of such payment from the Provider or the Insured. Legal Actions. No Insured Person can bring an action at law or in equity to recover on the Policy until more than 60 days after the date written proof of loss has been furnished according to the Policy. No such action may be brought after the expiration of three years after the time written proof of loss is required to be furnished. If the time limit of the Policy is less than allowed by the laws of the state where the Insured Person resides, the limit is extended to meet the minimum time allowed by such law. C-9184IN 7

GENERAL PROVISIONS Clerical Error. Clerical errors or delays in keeping records for the Policy will not deny insurance that would otherwise have been granted, nor extend insurance that otherwise would have ceased, and call for a fair adjustment of premium and benefits to correct the error. Conformity to Law. Any provision of the Policy that is in conflict with the laws of the state in which it is issued is amended to conform with the laws of that state. Entire Contract. The Policy, including any endorsements and riders, the Certificate, the Policyholder’s application, which is attached to the Policy when issued, the Insured’s individual enrollment form, if any, and the eligibility file, if any, are the entire contract between the parties. A copy of the Policy may be examined at the office of the Policyholder during normal business hours. All statements made by the Policyholder or an Insured will, in the absence of fraud, be deemed representations and not warranties, and no such statement will be used in defense to a claim hereunder unless it is contained in a written instrument signed by the Policyholder, the Insured, the Insured’s beneficiary or personal representative, a copy of which has been furnished to the Policyholder, the Insured, the Insured’s beneficiary or personal representative. Amendments and Changes. No agent is authorized to alter or amend the Policy, or to waive any conditions or restrictions herein, or to extend the time for paying any premium. The Policy and the Certificate may be amended at any time by mutual agreement between the Policyholder and the Company without the consent of the Insured, but without prejudice to any loss incurred prior to the effective date of the amendment. No person except an Officer of the Company has authority on behalf of the Company to modify the Policy or to waive or lapse any of the Company’s rights or requirements. Incontestability. After the Policy has been in force for two years, it can only be contested for nonpayment of premiums. No statement made by an Insured Person can be used in a contest after the Insured Person’s insurance has been in force for two years during the Insured Person’s lifetime. No statement an Insured Person makes can be used in a contest unless it is in writing and signed by the Insured Person. Insurance Data. The Policyholder must give the Company the names and ages of all individuals initially insured. The names of persons who later become eligible (whether or not the person becomes insured), and the names of those who cease to be eligible must also be given. The eligibility dates and any other necessary data must be given to the Company so that the premium can be determined. The Company has the right to audit the Policyholder’s books and records as the books and records relate to this insurance. The Company may authorize someone else to perform this audit. Any such inspection may be done at any reasonable time. Workers’ Compensation. The Policy is not a Workers’ Compensation policy. The Policy does not satisfy any requirement for coverage by Workers’ Compensation Insurance. C-9184IN 8

SCHEDULE OF BENEFITS Jay School Corporation BENEFIT FREQUENCY Vision Examination once every 12 months Insured Person Vision Materials Frame once every 24 months Insured Person Lenses and Lens Options once every 12 months Insured Person Contact Lenses once every 12 months Insured Person BENEFIT In-Network Out-of-Network Provider (Reimbursement up to) Plus In-Network In-Network Provider Provider Vision Examination Comprehensive Eye Examination $0 Copayment $0 Copayment $45 Vision Materials Frame $0 Copayment, $0 Copayment, $105 up to $200 Allowance up to $150 Allowance Contact Lenses Only one of the following Contact Lenses benefits may be used for the Contact Lenses benefit. Contact Lenses are in lieu of Lenses and Lens Options. Conventional $0 Copayment, $0 Copayment, $170 up to $200 Allowance up to $200 Allowance Disposable $0 Copayment, $0 Copayment, $170 up to $200 Allowance up to $200 Allowance Medically Necessary Paid in Full Paid in Full $300 Standard Plastic Lenses Single Vision $0 Copayment $0 Copayment $35 Bifocal $0 Copayment $0 Copayment $55 Trifocal $0 Copayment $0 Copayment $80 Lenticular $0 Copayment $0 Copayment $90 Progressive – Standard $55 Copayment $55 Copayment $50 Progressive – Premium $85 Copayment $85 Copayment $50 Tier 1 Progressive – Premium $95 Copayment $95 Copayment $50 Tier 2 Progressive – Premium $110 Copayment $110 Copayment $50 Tier 3 Progressive – Premium $175 Copayment $175 Copayment $50 Tier 4 S-9184 1A Exam/Materials

Jay School Corporation BENEFIT In-Network Out-of-Network Provider (Reimbursement up to) Plus In-Network In-Network Provider Provider Lens Options Anti-Reflective Coating – Standard $45 Copayment $45 Copayment $23 Anti-Reflective Coating – Premium $57 Copayment $57 Copayment $23 Tier 1 Anti-Reflective Coating – Premium $68 Copayment $68 Copayment $23 Tier 2 Anti-Reflective Coating – Premium $85 Copayment $85 Copayment $23 Tier 3 Photochromic Non-Glass Lens $0 Copayment $0 Copayment $38 Dependent Children under 19 years of age Polycarbonate Lenses – Standard $0 Copayment $0 Copayment $20 Dependent Children under 19 years of age Scratch Coating – Standard $0 Copayment $0 Copayment $8 Plastic S-9184 1B Exam/Materials

F I D E L I T Y S E C U R I T Y L I F E ® I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) AMENDATORY RIDER REGARDING REPLACEMENT COVERAGE The Policy/Certificate to which this Amendment Rider is attached is amended as follows: The following applies when the Policy serves to replace similar coverage the Policyholder previously obtained through another plan or policy. In this provision, that other plan or policy is referred to as the prior plan. The Policyholder’s coverage under the Policy will not be considered as replacement coverage unless the Policyholder’s coverage under the Policy takes effect within 60 days after coverage under the prior plan ends. In the absence of this provision, an Insured Person who was covered by the prior plan at the date of discontinuance might not qualify for coverage under the Policy because the person is not actively at work or is confined in a Hospital. Each such person will be insured under the Policy if: 1. the person was insured under the prior plan, including coverage under the prior plan’s extension of benefits provision, on the date the Policyholder’s coverage with the prior plan ended; 2. the prior plan covered more than 15 people; and 3. the person is in a class of persons eligible for coverage under the Policy. The benefits payable for the persons described above will be the benefits of the Policy less any amount payable under the prior plan pursuant to any extension of benefits provision. The Policy, in applying any waiting periods, will give credit for the satisfaction or partial satisfaction of the same or similar provisions under the prior policy. This Rider takes effect on the effective date of the Policy/Certificate to which it is attached. This Rider terminates concurrently with the Policy/Certificate to which it is attached. It is subject to all the terms and conditions of the Policy/Certificate except as stated herein. FIDELITY SECURITY LIFE INSURANCE COMPANY President Secretary R-02264 Rev 0719

F I D E L I T Y S E C U R I T Y L I F E ® I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) AMENDMENT RIDER By attachment of this Rider, the third paragraph of the PREMIUMS section in the Policy is amended to add the following: 5. if a government action, including fees, taxes and assessments, or change in law or regulation materially affects the Company’s risk, premium may be adjusted and will be effective upon written notification from the Company at least 31 days before the date of change. This Rider takes effect on the effective date of the Policy to which it is attached. This Rider terminates concurrently with the Policy to which it is attached. It is subject to all the definitions, limitations, exclusions and conditions of the Policy except as stated. FIDELITY SECURITY LIFE INSURANCE COMPANY President Secretary R-03006

F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) NOTICE TO POLICYHOLDERS Questions regarding your policy or coverage should be directed to: Fidelity Security Life Insurance Company Contact number: 1-800-648-8624 If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer, you may contact the Department of Insurance by mail, telephone or e-mail: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, IN 46204 Consumer Hotline: (800)-622-4461; (317)-232-2395 Complaints can be filed electronically at www.in.gov/idoi N-00050IN(04/05) 93-21448 Rev 04/05

F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y 3130 Broadway Kansas City, Missouri 64111-2406 Phone 800-648-8624 A STOCK COMPANY (Herein Called “the Company”) NOTICE OF PROTECTION PROVIDED BY THE INDIANA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Indiana Life and Health Insurance Guaranty Association (“ILHIGA”) and the protection it provides for policyholders. This safety net was created under Indiana law, which determines who and what is covered and the amounts of coverage. ILHIGA was established to provide protection to policyholders in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its insurance department. If this should happen, ILHIGA will typically arrange to continue coverage and pay claims, in accordance with Indiana law, with funding from assessments paid by other insurance companies. (For the purposes of this Notice, the terms “insurance company” and “insurer” mean and include health maintenance organizations (“HMOs”)). Basic Protections Currently Provided by ILHIGA Generally, an individual is covered by ILHIGA if the insurer was a member of ILHIGA and the individual lives in Indiana at the time the insurer is ordered into liquidation with a finding of insolvency. The coverage limits below apply only for companies placed in rehabilitation or liquidation on or after January 1, 2018. The benefits that ILHIGA is obligated to cover are not to exceed the lesser of (a) the contractual obligations for which the member insurer is liable or would have been liable if the member insurer were not an insolvent insurer, or (b) the limits indicated below: Life Insurance • $300,000 in death benefits • $100,000 in net cash surrender or net cash withdrawal values Health Insurance • $500,000 for health plan benefits (see definition below) • $300,000 in disability income and long-term care insurance benefits • $100,000 in other types of health insurance benefits Annuities • $250,000 in present value of annuity benefits (including net cash surrender and net cash withdrawal values) The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to health benefit plans and covered unallocated annuities. “Health benefit plan” is defined in IC 27-8-8-2(o), and generally includes hospital or medical expense policies, certificates, HMO subscriber contracts or certificates or other similar health contracts that provide comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide coverages for limited benefits (such as accident-only, credit, dental-only or vision-only insurance), Medicare Supplement insurance, disability income insurance and long-term care insurance. N-00074(IN) 93-33219 Rev 0519

The protections listed above apply only to the extent that benefits are payable under covered policy(s). In no event will the ILHIGA provide benefits greater than the contractual obligations in the life, annuity, or health insurance policy or contract. The statutory limits on ILHIGA coverage have changed over the years and coverage in prior years may not be the same as that set forth in this Notice. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or variable annuity contract. Benefits provided by a long-term care (LTC) rider to a life insurance policy or annuity contract shall be considered the same type of benefits as the base life insurance policy or annuity to which it relates. To learn more about the protections provided by ILHIGA, please visit the ILHIGA website at www.inlifega.org or contact: Indiana Life & Health Insurance Indiana Department of Insurance Guaranty Association 311 West Washington Street, Suite 103 3502 Woodview Trace, Suite 100 Indianapolis, IN 46204 Indianapolis, IN 46268 (317) 232-2385 (317) 636-8204 The policy or contract that this Notice accompanies might not be fully covered by ILHIGA and even if coverage is currently provided, coverage is (a) subject to substantial limitations and exclusions (some of which are described above), (b) generally conditioned on continued residence in Indiana, and (c) subject to possible change as a result of future amendments to Indiana law and court decisions. Complaints to allege a violation of any provision of the Indiana Life and Health Insurance Guaranty Association Act must be filed with the Indiana Department of Insurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone) 317-232-2385. Insurance companies and agents are not allowed by Indiana law to use the existence of ILHIGA or its coverage to encourage you to purchase any form of insurance or HMO coverage. (IC 27-8-8-18(a)). When selecting an insurance company, you should not rely on ILHIGA coverage. If there is any inconsistency between this Notice and Indiana law, Indiana law will control. Questions regarding the financial condition of a company or your life, health insurance policy or annuity should be directed to your insurance company or agent. 2

WHAT DOES Fidelity Security Life Insurance Company, Fidelity Security Life FACTS Insurance Company of New York (NY Only) and Affiliates DO WITH YOUR PERSONAL INFORMATION? Why? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. What? The types of personal information we collect and share depend on the product or service you have with us. This information can include: ■ Social Security number and transaction history ■ medical information and insurance claim information ■ assets and checking account information When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies need to share customers’ personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers’ personal information; the reasons Fidelity Security Life Insurance Company and Affiliates choose to share; and whether you can limit this sharing. Reasons we can share your personal information Does Fidelity Security Can you limit this Life share? sharing? For our everyday business purposes – such as to process your transactions, maintain your Yes No account(s), respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes – Yes No to offer our products and services to you For joint marketing with other financial companies Yes No For our affiliates’ everyday business purposes – Yes No information about your transactions and experiences For our affiliates’ everyday business purposes – No We don’t share information about your creditworthiness For our affiliates to market to you No We don’t share For nonaffiliates to market to you No We don’t share Questions? Call 800-648-8624 or go to www.fslins.com or www.ftj.com N-00200 93-33087 Rev 0912

Page 2 Who we are Who is providing this notice? Fidelity Security Life Insurance Company and Affiliates including our Administrative, Insurance and Financial Service Providers. What we do How does Fidelity Security Life To protect your personal information from unauthorized access and use, Insurance Company and Affiliates we use security measures that comply with federal law. These measures protect my personal information? include computer safeguards and secured files and buildings. These physical, electronic and procedural safeguards were created to protect your information. We also limit employee access as appropriate. How does Fidelity Security Life We collect your personal information, for example, when you Insurance Company and Affiliates collect my personal information? ■ apply for insurance or pay insurance premiums ■ file an insurance claim or give us your contact information ■ show your driver’s license We also collect your personal information from others, such as credit bureaus, affiliates, or other companies. Why can’t I limit all sharing? Federal law gives you the right to limit only ■ sharing for affiliates’ everyday business purposes – information about your creditworthiness ■ affiliates from using your information to market to you ■ sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. Definitions Affiliates Companies related by common ownership or control. They can be financial and nonfinancial companies. ■ Our affiliates include Fidelity Security Life Insurance Company of New York, Forrest T. Jones & Company, Inc., Forrest T. Jones Consulting Company and National Pension & Group Consultants, Inc. Nonaffiliates Companies not related by common ownership or control. They can be financial and nonfinancial companies. ■ Fidelity Security Life Insurance Company does not share with nonaffiliates so they can market to you. Joint marketing A formal agreement between nonaffiliated financial companies that together market financial products or services to you. ■ Our joint marketing partners include insurance agencies, broker dealers and investment advisor firms. Other important information 2

Application for Vision Care Benefits Underwritten by Fidelity Security Life Insurance Company KansasCity, Missouri 64111 I. GROUPINFORMATION Jay School Corporation 35-1100185 GroupName: Tax ID#: DBAName(Ifotherthanabove): Business Physical Address: 414 Floral Ave. Portland IN 47371 (Street Address) (City) (State) (Zip) Mailing Address: POBox1239 Portland IN 47371 (Street Address) (City) (State) (Zip) Day-to-Day Contact Name: ShannonCurrent Title: Business Manager PhoneNumber: ( ) 260-726-9341 E-Mail Address: scurrent@jayschools.k12.in.us Type of Business: Proprietorship Corporation Other (Specify): PLEASENOTETHEFOLLOWINGTYPEBUSINESSESREQUIREPRIORCARRIERAPPROVAL: MEWA PEO Trust Union VEBA Casino/Indian Tribe Service Area: National (U.S. does not include Puerto Rico) XStateSpecific* National (U.S. does include Puerto Rico) Ohio GROUPDISPLAYNAME CompanyName: JaySchoolCorporation (Maximumof 40characters, including capitalization, punctuation and spacing.) II. GROUPBILLING Billing Physical Address: 414Floral Ave. Portland IN 47371 (Street Address) (City) (State) (Zip) PrimaryContact Name: Irene Taylor Title: Deputy Treasurer PhoneNumber: ( )260-726-9341 E-Mail Address: itaylor@jayschools.k12.in.us III. PREMIUMS* Please indicate the percentage of premium contributed by the Group and the Employee/Member for both the Employee/Member and Dependents; the total for each row must equal 100%. GroupContribution Employee/Member Contribution Employee/Members: 70 % 30 % Dependents: 70 % 30 % Are Employee/Member and Dependent premiums paid through a Section 125 Plan? XYes No Are Employee/Member and Dependent premiums collected via payroll deduction? XYes No Premiums shall be payable at the rates included on the attached proposal page. A-01224IN M-9184/M-9185/M-9186/M-9191

IV. ELIGIBILITY NumberofEligible Employees/Members: 338 Will this plan replace any existing vision coverage? XYes No AnthemBlueViewVision Eligible Class(es) of Employees/Members (please check all that apply): X Active employees X Retiree / Leave of Absence X COBRA eligible employees Other: Arethefollowing covered under the plan: Domestic Partners:* Yes X No If Yes, Same Sex:* Yes No Opposite Sex:* Yes No Dependent Children Covered to Age*: 26** Other Dependent Children who are full-time students covered to age*: 27 XOther 26 Dependent Child Age Termination based on: DayAgeisattained EndofMonthAgeisattained X Endof Year Age is attained MEMBERSHIPINFORMATION Whowill send enrollment for Active Employees/Members? X Group TPA If TPA, TPA Name: Group/TPAContact Name: Irene Taylor PhoneNumber: ( )260-726-9341 E-Mail Address: itaylor@jayschools.k12.in.us Membership will be an electronic membership file? X Yes No Whowill send enrollment for COBRA Employees/Members? X Group TPA If TPA, TPA Name: Group/TPAContact Name: Irene Taylor PhoneNumber: ( ) 260-726-9341 E-Mail Address: itaylor@jayschools.k12.in.us Membership will be an electronic membership file? X Yes No PROBATIONARYPERIOD For New Employees/Members: 30days 60days 90days 180days Other 1stmo.after hire Probationary Period is waived for present Employees/Members: Yes No NumberofEmployees/Memberswhohavenot yet completedthe probationary period: 0 V. PLANSELECTION Please refer to the attached proposal page. Services are provided by EyeMed Vision Care. A-01224IN 2

Nicklaus Napier

DocuSign Envelope ID: 757DDB57-C7BE-4305-B022-978E6DD158FD Jay School Corporation VISION CARE IN-NETWORK OUT-OF-NETWORK SERVICES MEMBER COST MEMBER REIMBURSEMENT EXAM SERVICES Exam at PLUS Providers $0 copay Up to $45 Exam $0 copay Up to $45 Proposed Benefits FRAME EyeMed Vision Care in Any available frame at PLUS Providers $0 copay; 20% off balance over $200 allowance Up to $105 conjunction with Fidelity Frame $0 copay; 20% off balance over $150 allowance Up to $105 Security Life Insurance Company CONTACT LENSES Option SHARED (Contact Lens allowance includes materials only) Exam & Materials Contacts - Conventional $0 copay; 15% off balance over $200 allowance Up to $170 Contacts - Disposable $0 copay; 100% of balance over $200 allowance Up to $170 Insight Network Contacts - Medically Necessary $0 copay; paid-in-full Up to $300 Fully Insured STANDARD PLASTIC LENSES Shared Expense Single Vision $0 copay Up to $35 Bifocal $0 copay Up to $55 Funded Benefits Trifocal $0 copay Up to $80 Lenticular $0 copay Up to $90 Frequency Progressive - Standard $55 copay Up to $50 Progressive - Premium Tier 1 $85 copay Up to $50 Progressive - Premium Tier 2 $95 copay Up to $50 Examination Progressive - Premium Tier 3 $110 copay Up to $50 Once every plan year Progressive - Premium Tier 4 $175 copay Up to $50 Lenses (in lieu of contacts) LENS OPTIONS Once every plan year Anti Reflective Coating - Standard $45 copay Up to $23 Contacts (in lieu of lenses) Anti Reflective Coating - Premium Tier 1 $57 copay Up to $23 Once every plan year Anti Reflective Coating - Premium Tier 2 $68 copay Up to $23 Frame Anti Reflective Coating - Premium Tier 3 $85 copay Up to $23 Once every other plan year Polycarbonate - Std < 19 years of age $0 copay Up to $20 Scratch Coating - Standard Plastic $0 copay Up to $8 Terms Photochromic – Non-Glass < 19 years of age $0 copay Up to $38 Contract Term 48 months Rate Guarantee 48 months MONTHLY RATES Subscriber $9.73 Subscriber + Family $24.00 Monthly Rate is subject to adjustment even during a rate guarantee period in the event of any of the following events: changes in benefits, employee contributions, the number of eligible employees, or the imposition of any new taxes, fees or assessments by Federal or State regulatory agencies. The Plan reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. PLAN DETAILS Quote for group sitused in the State of IN and will be valid until the 09/01/2022 implementation date. Date Quoted 07/18/2022. Rates are valid only when the quoted plan is the sole stand-alone vision plan offered by the group. Percentage discounts are not part of the insurance benefit. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-146, form number M-9184. PLAN EXCLUSIONS/LIMITATIONS No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (non-prescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state. By signing below, the Group agrees to receive all documents and correspondence electronically and that the Group can access the internet or the email address provided. The Group understands that the Group may revoke this authorization or request specific paper documents without revoking this authorization by contacting EyeMed by mail, email, or telephone. If Jay School Corporation has chosen this benefit design, attach this document to the group application and sign here 8/3/2022 | 8:25 AM CDT \d2\ \s2\ Signature Date P201603 TC - 10 Q-00041991 – QL-0000071368