APPLICATION FOR GROUP ACCIDENT POLICY RELIANCE STANDARD LIFE INSURANCE COMPANY PHILADELPHIA, PENNSYLVANIA GROUP POLICY NUMBER: VAI 877407 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 is attached to your Policy and the other is to be 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: ______________________________________ Federal Employer Identification Number: 35-1099157 By: _____________________________________________ (Signature) ________________________________________________ (Title) LRS-9547-0318-IN