POLICY SPECIFICATIONS POLICY EFFECTIVE DATE: This policy will take effect on the effective date shown on page 1. ELIGIBLE CLASS(ES): All active employees of the policyholder who work 15 or more hours a week. Eligible Dependents: Spouse and Child(ren) of eligible employees or members. ELIGIBILITY WAITING PERIOD: None LIFE INSURANCE BENEFIT: Amount selected by the employee or member – Up to $150,000 ADDITIONAL BENEFITS: Portability Privilege Insured’s Life Insurance Benefit amount, up to $150,000 Other Support Services This policy may include enrollment, risk management, and other support services related to the policyholder’s benefit program. REQUIRED RIDERS: Accelerated Death Benefit 75% of Insured’s Life Insurance, up to $100,000 for Terminal Illness or Condition Rider Accelerated Death Benefit Acceleration Percentage: 4% for Long Term Care with Extension of Benefits Rider OPTIONAL RIDERS: None GWLPIN Page 3