RELIANCE STANDARD LIFE INSURANCE COMPANY Home Office: Schaumburg, Illinois Administrative Office: Philadelphia, Pennsylvania GROUP POLICY NUMBER: LTD 134339 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-6564-1 Ed. 2/83