RELIANCE STANDARD LIFE INSURANCE COMPANY Philadelphia, Pennsylvania GROUP POLICY NUMBER: GL 166285 POLICY EFFECTIVE DATE: January 1, 2023 POLICY DELIVERED IN: Indiana ANNIVERSARY DATE: January 1st in each year Application is made to us by: Goshen Community Schools This Application is completed in duplicate, one copy to be attached to your Policy and the other returned to us. It is agreed that this Application takes the place of any previous application for your Policy. Signed at _________________________________ this _______ day of ______________________________________ Policyholder: __________________________________________ By: ___________________________________________________ (Signature) ______________________________________________________ (Title) LRS-6422-A Ed. 3/82