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