Voluntary Critical Illness Certificate

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania 1700 Market Street, Suite 1200, Phila., PA 19103-3938 (800) 351-7500 WHERE TO FIND: Page SCHEDULE OF BENEFITS ................................................................................................................................................. 1.0 DEFINITIONS ....................................................................................................................................................................... 2.0 TRANSFER OF INSURANCE COVERAGE ........................................................................................................................ 3.0 GENERAL PROVISIONS ..................................................................................................................................................... 4.0 INDIVIDUAL ELIGIBILITY, EFFECTIVE DATE AND TERMINATION ................................................................................. 5.0 DEPENDENT CRITICAL ILLNESS INSURANCE ................................................................................................................ 6.0 PORTABILITY ...................................................................................................................................................................... 7.0 BENEFIT PROVISIONS ....................................................................................................................................................... 8.0 WELLNESS BENEFIT .......................................................................................................................................................... 9.0 BENEFICIARY AND FACILITY OF PAYMENT ................................................................................................................. 10.0 CLAIMS PROVISIONS ....................................................................................................................................................... 11.0 PREMIUMS ........................................................................................................................................................................ 12.0 EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ............................................................. 13.0 EXCLUSIONS .................................................................................................................................................................... 14.0 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. VCI 877405 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. Secretary President READ THIS CERTIFICATE CAREFULLY. THE POLICY PROVIDES A LIMITED BENEFIT FOR CERTAIN CRITICAL ILLNESSES. THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY OR MEDICAL INSURANCE POLICY. RECEIPT OF BENEFITS UNDER THE POLICY MAY AFFECT ELIGIBILITY FOR MEDICAID OR OTHER GOVERNMENT BENEFITS AND/OR ENTITLEMENTS. THE POLICY IS OPTIONALLY RENEWABLE. GROUP CRITICAL ILLNESS CERTIFICATE LRS-9538-0118 Ed. 2/2023