Group Life (Basic and Term) Policy

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania POLICYHOLDER: Goshen Community Schools POLICY NUMBER: GL 166285 EFFECTIVE DATE: January 1, 2023 ANNIVERSARY DATES: January 1, 2024 and each January 1st thereafter. PREMIUM DUE DATES: The first premium is due on the Effective Date. Further premiums are due monthly, in advance, on the first day of each month. The Policy is delivered in Indiana and is governed by its laws. We agree to provide insurance to you in exchange for the payment of premium and a signed Application. The Policy provides benefits for loss of life from injury or sickness. It insures the eligible persons for the amount of insurance shown on the Schedule of Benefits. The insurance is subject to the terms and conditions of the Policy. The effective date of the Policy is shown above. Insurance starts and ends at 12:01 A.M., Local Time, at your main address. It stays in effect as long as premium is paid when due. The "TERMINATION OF THE POLICY" section of the GENERAL PROVISIONS explains when the insurance can be ended. The Policy is signed by the President and Secretary. Secretary President GROUP LIFE INSURANCE NON-PARTICIPATING LRS-6422 Ed. 2/84