RELIANCE STANDARD LIFE INSURANCE COMPANY Philadelphia, Pennsylvania GROUP POLICY NUMBER: VPS 329289 POLICY EFFECTIVE DATE: January 1, 2023 POLICY DELIVERED IN: ANNIVERSARY DATE: January 1st in each year Indiana 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) Please sign and return. *BOD* LRS-6451-A Ed. 4/82