STANDARD INSURANCE COMPANY A Stock Life Insurance Company 900 SW Fifth Avenue Portland, Oregon 97204-1282 (503) 321-7000 CERTIFICATE GROUP LONG TERM DISABILITY INSURANCE Policyholder: Washington State Health Care Authority Policy Number: 377661-B Effective Date: July 1, 1992 and as amended A Group Policy has been issued to the Policyholder. We certify that you will be insured as provided by the terms of the Group Policy. If your coverage is changed by an amendment to the Group Policy, we will provide the Policyholder with a revised Certificate or other notice to be given to you. Possession of this Certificate does not necessarily mean you are insured. You are insured only if you meet the requirements set out in this Certificate. "We", "us" and "our" mean Standard Insurance Company. "You" and "your" mean the Member. All other defined terms appear with the initial letter capitalized. Section headings, and references to them, appear in boldface type. GC190-LTD 377661-B SI 22516 (8/22)