POLICY SPECIFICATIONS (Continued) PREMIUM DUE: January 1, 2022 and the first day of each calendar month thereafter. All premiums must be sent to us on or before the premium due date. The premium must be paid in United States dollars. TOBACCO RATING BASIS: Tobacco/Non-Tobacco MINIMUM PARTICIPATION REQUIREMENT The minimum participation required by the governing jurisdiction or a minimum of 5 insured employees or members, whichever is greater, is required to issue this policy. DIVISIONS, SUBSIDIARIES, OR AFFILIATED COMPANIES These are the policyholder’s divisions, subsidiaries, or affiliates listed below. The policyholder may act for and on behalf of any and all of these in all matters that pertain to this policy. Every act done by, agreement made with, or notice given to the policyholder will be binding on them. Name Location (City and State) None GWLPIN Page 3C