Voluntary Short Term Disability Policy

Home Office: Schaumburg, Illinois • Administrative Office: Philadelphia, Pennsylvania POLICYHOLDER: Goshen Community Schools POLICY NUMBER: VPS 329289 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. The Policy provides benefits for loss of time due to disability from sickness or injury. It insures those eligible persons for the benefits shown on the Schedule of Benefits. The insurance is subject to the terms and conditions of the Policy. The effective date of the 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 "TERMINATION OF THE POLICY" section of the GENERAL PROVISIONS explains when the insurance can be ended. The Policy is signed by the President and Secretary. Secretary President GROUP WEEKLY INCOME INSURANCE NON-PARTICIPATING CONTRIBUTORY LRS-6451 Ed. 0406