Voluntary Accident Certificate

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania WHERE TO FIND Page SCHEDULE OF BENEFITS ............................................................................................................................................... 1.0 DEFINITIONS ..................................................................................................................................................................... 2.0 GENERAL PROVISIONS ................................................................................................................................................... 3.0 INDIVIDUAL ELIGIBILITY, EFFECTIVE DATE AND TERMINATION ............................................................................... 4.0 DEPENDENT INSURANCE ............................................................................................................................................... 5.0 PORTABILITY ..................................................................................................................................................................... 6.0 BENEFIT PROVISIONS ..................................................................................................................................................... 7.0 WELLNESS BENEFIT ........................................................................................................................................................ 8.0 BENEFICIARY AND FACILITY OF PAYMENT ................................................................................................................. 9.0 CLAIMS PROVISIONS ..................................................................................................................................................... 10.0 PREMIUMS ...................................................................................................................................................................... 11.0 EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ........................................................... 12.0 EXCLUSIONS .................................................................................................................................................................. 13.0 CERTIFICATE OF INSURANCE We certify that you (provided you belong to a class described on the Schedule of Benefits) are insured for the benefits which apply to your class, under Group Policy No. VAI 877407 issued to Goshen Community Schools, the Policyholder. This Certificate is not a contract of insurance. It contains only the major terms of insurance coverage and payment of benefits under the Policy. Coverage is subject to the terms and conditions of the Policy. In the event of a conflict between the Policy and this Certificate, the terms of the Policy control. Secretary President READ THIS CERTIFICATE CAREFULLY. THE POLICY PROVIDES LIMITED BENEFITS. THE POLICY IS NOT A MEDICAL INSURANCE POLICY GROUP ACCIDENT CERTIFICATE LRS-9548-0318-IN Ed. 2/2023