Voluntary Critical Illness Policy

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania 1700 Market Street, Suite 1200, Phila., PA 19103-3938 (800) 351-7500 POLICYHOLDER: Goshen Community Schools POLICY NUMBER: VCI 877405 EFFECTIVE DATE: January 1, 2023 ANNIVERSARY DATES: January 1, 2024 and each January 1st thereafter. PREMIUM DUE DATES: The first premium is due on the effective date. Further premiums are due monthly, in advance, on the first day of each month. This Policy is delivered in Indiana and is governed by its laws and/or the Employee Retirement Income Security Act of 1974 ("ERISA") as amended, where applicable. We agree to provide insurance to you in exchange for the payment of premium and a signed Application. This Policy provides benefits if an Insured suffers Critical Illness as defined herein, subject to any limitations and exclusions set forth. It insures the eligible persons for the Amount of Insurance shown on the Schedule of Benefits. The insurance is subject to the terms and conditions of this Policy. In the event of a conflict between this Policy and the Certificate, the terms of the Policy control. The Effective Date of this Policy is shown above. Insurance starts and ends at 12:01 A.M., Local Time, at your main address. It stays in effect as long as premium is paid when due. The "POLICY TERMINATION" section of the GENERAL PROVISIONS explains when the insurance can be ended. This Policy is signed by our President and Secretary. Secretary President READ THIS POLICY CAREFULLY. THIS POLICY PROVIDES A LIMITED BENEFIT FOR CERTAIN CRITICAL ILLNESSES. THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY OR MEDICAL INSURANCE POLICY. RECEIPT OF BENEFITS UNDER THIS POLICY MAY AFFECT ELIGIBILITY FOR MEDICAID OR OTHER GOVERNMENT BENEFITS AND/OR ENTITLEMENTS. THIS POLICY IS OPTIONALLY RENEWABLE. GROUP CRITICAL ILLNESS POLICY LRS-9537-0118