401k Plan data: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN plan

AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN
Plan identification number	501

AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

AMERICAN NATIONAL STANDARDS INSTITUTE, INC. has sponsored the creation of one or more 401k plans.

Company Name: AMERICAN NATIONAL STANDARDS INSTITUTE, INC.

Employer identification number (EIN): 131635253

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 LAWRENCE L. CASTIGLIONE 2023-05-26
501 2021-01-01 LAWRENCE L. CASTIGLIONE 2022-07-06
501 2020-01-01 LAWRENCE L. CASTIGLIONE 2021-08-05
501 2019-01-01 MARGARET JENSEN 2020-08-21
501 2018-01-01 LAWRENCE CASTIGLIONE 2019-10-10
501 2017-01-01
501 2016-01-01 MARGARET JENSEN
501 2015-06-01
501 2015-01-01 LAWRENCE L CASTIGLIONE
501 2014-06-01
501 2013-06-01
501 2012-06-01 MARGARET JENSEN 2013-12-23

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	LAWRENCE L. CASTIGLIONE	2023-05-26
501	2021-01-01	LAWRENCE L. CASTIGLIONE	2022-07-06
501	2020-01-01	LAWRENCE L. CASTIGLIONE	2021-08-05
501	2019-01-01	MARGARET JENSEN	2020-08-21
501	2018-01-01	LAWRENCE CASTIGLIONE	2019-10-10
501	2017-01-01
501	2016-01-01	MARGARET JENSEN
501	2015-06-01
501	2015-01-01	LAWRENCE L CASTIGLIONE
501	2014-06-01
501	2013-06-01
501	2012-06-01	MARGARET JENSEN	2013-12-23

Plan Statistics for AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN

401k plan membership statisitcs for AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN

Measure Date Value
2022: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 193
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 203
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 203
Number of employers contributing to the scheme 2022-01-01 0
2021: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 193
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 193
Number of employers contributing to the scheme 2021-01-01 0
2020: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 195
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 195
Number of employers contributing to the scheme 2020-01-01 0
2019: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 188
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 188
Number of employers contributing to the scheme 2019-01-01 0
2018: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 103
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 103
Number of employers contributing to the scheme 2018-01-01 0
2017: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 105
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 105
2016: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 111
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 111
2015: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 105
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 105

Measure	Date	Value
2022: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	193
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	203
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	203
Number of employers contributing to the scheme	2022-01-01	0
2021: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	193
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	193
Number of employers contributing to the scheme	2021-01-01	0
2020: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	195
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	195
Number of employers contributing to the scheme	2020-01-01	0
2019: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	188
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	188
Number of employers contributing to the scheme	2019-01-01	0
2018: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	103
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	103
Number of employers contributing to the scheme	2018-01-01	0
2017: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	105
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	105
2016: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	111
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	111
2015: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	105
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	105

Form 5500 Responses for AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN

2022: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: AMERICAN NATIONAL STANDARDS INSTITUTE WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	194
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,997
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $33,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,997
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

242263

Policy instance

Insurance contract or identification number	242263
Number of Individuals Covered	381
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $133,775
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,239,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $133,775
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05585937

Policy instance

Insurance contract or identification number	TM05585937
Number of Individuals Covered	402
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,309
Total amount of fees paid to insurance company	USD $2,239
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,309
Amount paid for insurance broker fees	2232
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	79
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $8,203
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $54,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,203
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

563920

Policy instance

Insurance contract or identification number	563920
Number of Individuals Covered	203
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $2,803
Total amount of fees paid to insurance company	USD $481
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $41,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,802
Amount paid for insurance broker fees	481
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9907-85-30

Policy instance

Insurance contract or identification number	9907-85-30
Number of Individuals Covered	203
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,917
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $12,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,917
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

895680G

Policy instance

Insurance contract or identification number	895680G
Number of Individuals Covered	203
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,582
Total amount of fees paid to insurance company	USD $12,499
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $205,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,582
Amount paid for insurance broker fees	12499
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	193
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $24,507
Total amount of fees paid to insurance company	USD $3,063
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $249,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,507
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

242263

Policy instance

Insurance contract or identification number	242263
Number of Individuals Covered	363
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $132,425
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,180,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $132,425
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5585937

Policy instance

Insurance contract or identification number	5585937
Number of Individuals Covered	398
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,768
Total amount of fees paid to insurance company	USD $2,027
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,768
Amount paid for insurance broker fees	2023
Additional information about fees paid to insurance broker	NON-MONETARY AND SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	84
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $7,173
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $47,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,173
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

563920

Policy instance

Insurance contract or identification number	563920
Number of Individuals Covered	194
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $3,446
Total amount of fees paid to insurance company	USD $659
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $46,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,446
Amount paid for insurance broker fees	659
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9907-85-30

Policy instance

Insurance contract or identification number	9907-85-30
Number of Individuals Covered	193
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	195
Insurance policy start date	2021-05-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,215
Total amount of fees paid to insurance company	USD $1,902
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $114,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,215
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	179
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,896
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $32,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,082
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

563920

Policy instance

Insurance contract or identification number	563920
Number of Individuals Covered	198
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $9,648
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $32,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,648
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	86
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $8,023
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $53,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,023
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5585937

Policy instance

Insurance contract or identification number	5585937
Number of Individuals Covered	397
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,825
Total amount of fees paid to insurance company	USD $1,862
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,825
Amount paid for insurance broker fees	1848
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	176
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,981
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,981
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

242263

Policy instance

Insurance contract or identification number	242263
Number of Individuals Covered	363
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $130,642
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,575,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130,642
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	195
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $19,753
Total amount of fees paid to insurance company	USD $2,469
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $211,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,061
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9907-85-30

Policy instance

Insurance contract or identification number	9907-85-30
Number of Individuals Covered	195
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	188
Insurance policy start date	2018-05-01
Insurance policy end date	2019-04-30
Total amount of commissions paid to insurance broker	USD $16,097
Total amount of fees paid to insurance company	USD $2,012
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $149,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,097
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

AN6654

Policy instance

Insurance contract or identification number	AN6654
Number of Individuals Covered	373
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $134,806
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,706,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $134,806
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	185
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,920
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,920
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5585937

Policy instance

Insurance contract or identification number	5585937
Number of Individuals Covered	446
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,735
Total amount of fees paid to insurance company	USD $1,652
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,735
Amount paid for insurance broker fees	1640
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	87
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $7,789
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $51,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,789
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	125
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $13,075
Total amount of fees paid to insurance company	USD $1,634
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $131,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,075
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

AN6654

Policy instance

Insurance contract or identification number	AN6654
Number of Individuals Covered	241
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $91,980
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,332,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,980
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	185
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,553
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,553
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5585937

Policy instance

Insurance contract or identification number	5585937
Number of Individuals Covered	226
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,454
Total amount of fees paid to insurance company	USD $1,110
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,454
Amount paid for insurance broker fees	1101
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	90
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $7,132
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $47,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,132
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	114
Insurance policy start date	2016-05-01
Insurance policy end date	2017-04-30
Total amount of commissions paid to insurance broker	USD $11,778
Total amount of fees paid to insurance company	USD $1,472
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $118,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,778
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	GALLAGHER BENEFIT SERVICES

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

AN6654

Policy instance

Insurance contract or identification number	AN6654
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $79,404
Total amount of fees paid to insurance company	USD $1,725
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,996,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,404
Amount paid for insurance broker fees	1725
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	4
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	123
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,403
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,403
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05585937

Policy instance

Insurance contract or identification number	TM05585937
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,247
Total amount of fees paid to insurance company	USD $1,084
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,247
Amount paid for insurance broker fees	1084
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION ADMINISTRATION FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

45148-LTC

Policy instance

Insurance contract or identification number	45148-LTC
Number of Individuals Covered	96
Insurance policy start date	2016-06-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $8,045
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $53,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,045
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

GVNY4991

Policy instance

Insurance contract or identification number	GVNY4991
Number of Individuals Covered	175
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,306
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,306
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

AN6654

Policy instance

Insurance contract or identification number	AN6654
Number of Individuals Covered	208
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $74,972
Total amount of fees paid to insurance company	USD $1,365
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,871,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74,972
Amount paid for insurance broker fees	1365
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES,INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

405104

Policy instance

Insurance contract or identification number	405104
Number of Individuals Covered	105
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $10,117
Total amount of fees paid to insurance company	USD $2,529
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $101,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,117
Insurance broker organization code?	3
Amount paid for insurance broker fees	2529
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05585937

Policy instance

Insurance contract or identification number	TM05585937
Number of Individuals Covered	225
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,986
Total amount of fees paid to insurance company	USD $1,150
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $66,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,986
Amount paid for insurance broker fees	1069
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE

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Company Name:	AMERICAN NATIONAL STANDARDS INSTITUTE, INC.
Employer identification number (EIN):	131635253
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services