401k Plan data: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN plan

THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN
Plan identification number	501

THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Supplemental unemployment Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

THE MONTEFIORE HOME INC. has sponsored the creation of one or more 401k plans.

Company Name: THE MONTEFIORE HOME INC.

Employer identification number (EIN): 340714360

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 SETH VILENSKY
501 2016-01-01 SETH VILENSKY
501 2015-01-01 SETH VILENSKY
501 2014-01-01 SETH VILENSKY
501 2013-01-01 LAUREN ROCK
501 2012-01-01 LAUREN ROCK
501 2011-01-01 LAUREN ROCK
501 2009-01-01 LAUREN ROCK

Plan Statistics for THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN

Measure Date Value
2020: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 219
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
Total participants 2020-01-01 0
2019: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 219
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 216
Number of retired or separated participants receiving benefits 2019-01-01 3
Total of all active and inactive participants 2019-01-01 219
Total participants 2019-01-01 219
2018: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 464
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 211
Number of retired or separated participants receiving benefits 2018-01-01 4
Total of all active and inactive participants 2018-01-01 215
Total participants 2018-01-01 215
2017: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 492
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 464
Total of all active and inactive participants 2017-01-01 464
Total participants 2017-01-01 464
2016: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 405
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 492
Total of all active and inactive participants 2016-01-01 492
Total participants 2016-01-01 492
2015: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 568
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 405
Total of all active and inactive participants 2015-01-01 405
Total participants 2015-01-01 405
2014: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 584
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 568
Total of all active and inactive participants 2014-01-01 568
Total participants 2014-01-01 568
2013: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 401
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 584
Total of all active and inactive participants 2013-01-01 584
Total participants 2013-01-01 584
2012: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 393
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 397
Number of retired or separated participants receiving benefits 2012-01-01 4
Total of all active and inactive participants 2012-01-01 401
Total participants 2012-01-01 401
2011: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 431
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 389
Number of retired or separated participants receiving benefits 2011-01-01 4
Total of all active and inactive participants 2011-01-01 393
Total participants 2011-01-01 393
2009: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 486
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 545
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 545
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 545
Number of participants with account balances 2009-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2020: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	219
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
Total participants	2020-01-01	0
2019: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	219
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	216
Number of retired or separated participants receiving benefits	2019-01-01	3
Total of all active and inactive participants	2019-01-01	219
Total participants	2019-01-01	219
2018: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	464
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	211
Number of retired or separated participants receiving benefits	2018-01-01	4
Total of all active and inactive participants	2018-01-01	215
Total participants	2018-01-01	215
2017: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	492
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	464
Total of all active and inactive participants	2017-01-01	464
Total participants	2017-01-01	464
2016: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	405
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	492
Total of all active and inactive participants	2016-01-01	492
Total participants	2016-01-01	492
2015: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	568
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	405
Total of all active and inactive participants	2015-01-01	405
Total participants	2015-01-01	405
2014: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	584
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	568
Total of all active and inactive participants	2014-01-01	568
Total participants	2014-01-01	568
2013: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	401
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	584
Total of all active and inactive participants	2013-01-01	584
Total participants	2013-01-01	584
2012: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	393
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	397
Number of retired or separated participants receiving benefits	2012-01-01	4
Total of all active and inactive participants	2012-01-01	401
Total participants	2012-01-01	401
2011: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	431
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	389
Number of retired or separated participants receiving benefits	2011-01-01	4
Total of all active and inactive participants	2011-01-01	393
Total participants	2011-01-01	393
2009: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	486
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	545
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	545
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	545
Number of participants with account balances	2009-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Form 5500 Responses for THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN

2020: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	Yes
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: THE MONTEFIORE HOME FLEXIBLE BENEFIT 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: THE MONTEFIORE HOME FLEXIBLE BENEFIT 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
2014: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan is a collectively bargained plan	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: THE MONTEFIORE HOME FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan is a collectively bargained plan	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

0089820-01

Policy instance

Insurance contract or identification number	0089820-01
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 $24,595
Total amount of fees paid to insurance company	USD $27,093
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,595
Amount paid for insurance broker fees	27093
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

00617314

Policy instance

Insurance contract or identification number	00617314
Number of Individuals Covered	227
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,242
Total amount of fees paid to insurance company	USD $2,512
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, VOL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $83,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,242
Amount paid for insurance broker fees	2512
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	11
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $43
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,357
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
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000025684

Policy instance

Insurance contract or identification number	0000025684
Number of Individuals Covered	76
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $18,080
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,449
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	172
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	11
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $48
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,651
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
Insurance broker organization code?	3

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

0073643-01

Policy instance

Insurance contract or identification number	0073643-01
Number of Individuals Covered	218
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $27,088
Total amount of fees paid to insurance company	USD $32,053
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,088
Amount paid for insurance broker fees	32053
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	481
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

00617314

Policy instance

Insurance contract or identification number	00617314
Number of Individuals Covered	236
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,620
Total amount of fees paid to insurance company	USD $3,696
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, VOL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $123,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,620
Amount paid for insurance broker fees	3696
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000025684

Policy instance

Insurance contract or identification number	0000025684
Number of Individuals Covered	76
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,424
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,814
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	69
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $2,418
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $16,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,418
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	214
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404003385

Policy instance

Insurance contract or identification number	404003385
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $-373
Total amount of fees paid to insurance company	USD $200
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $3,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-373
Amount paid for insurance broker fees	200
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	161
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,842
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,842
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10118094

Policy instance

Insurance contract or identification number	10118094
Number of Individuals Covered	33
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,081
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,081
Insurance broker organization code?	3
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	POOLED AD&D

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

405004135

Policy instance

Insurance contract or identification number	405004135
Number of Individuals Covered	16
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $221
Total amount of fees paid to insurance company	USD $260
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $4,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $221
Amount paid for insurance broker fees	260
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

0073643-01

Policy instance

Insurance contract or identification number	0073643-01
Number of Individuals Covered	215
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $27,236
Total amount of fees paid to insurance company	USD $23,634
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,236
Amount paid for insurance broker fees	23634
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010206358

Policy instance

Insurance contract or identification number	000010206358
Number of Individuals Covered	35
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,267
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $8,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,267
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10118093

Policy instance

Insurance contract or identification number	10118093
Number of Individuals Covered	33
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $822
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $822
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	12
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $57
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,951
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
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	199
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,243
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,243
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	28
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $456
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	CHILD LIFE, SPOUSE AD&D/LIFE AD&D/L
Welfare Benefit Premiums Paid to Carrier	USD $2,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $456
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
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 $2,352
Total amount of fees paid to insurance company	USD $1,649
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,352
Amount paid for insurance broker fees	1649
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	160
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,868
Total amount of fees paid to insurance company	USD $1,574
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,868
Amount paid for insurance broker fees	1574
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	464
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404003385

Policy instance

Insurance contract or identification number	404003385
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $801
Total amount of fees paid to insurance company	USD $405
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $6,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $801
Amount paid for insurance broker fees	405
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010206358

Policy instance

Insurance contract or identification number	000010206358
Number of Individuals Covered	42
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,949
Total amount of fees paid to insurance company	USD $1,481
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $39,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,949
Amount paid for insurance broker fees	1481
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10118093

Policy instance

Insurance contract or identification number	10118093
Number of Individuals Covered	39
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $361
Total amount of fees paid to insurance company	USD $267
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $361
Amount paid for insurance broker fees	267
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

405004135

Policy instance

Insurance contract or identification number	405004135
Number of Individuals Covered	22
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $815
Total amount of fees paid to insurance company	USD $607
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $8,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $815
Amount paid for insurance broker fees	607
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	33
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,931
Total amount of fees paid to insurance company	USD $315
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	CHILD LIFE, SPOUSE AD&D/LIFE AD&D/L
Welfare Benefit Premiums Paid to Carrier	USD $9,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,931
Amount paid for insurance broker fees	315
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	83
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,572
Total amount of fees paid to insurance company	USD $1,170
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $10,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,572
Amount paid for insurance broker fees	1170
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	15
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $70
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14
Insurance broker organization code?	3
Insurance broker name	CBF BENEFITS INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10118094

Policy instance

Insurance contract or identification number	10118094
Number of Individuals Covered	39
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $524
Total amount of fees paid to insurance company	USD $297
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $524
Amount paid for insurance broker fees	297
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 95828 )

Policy contract number

0062909-01

Policy instance

Insurance contract or identification number	0062909-01
Number of Individuals Covered	206
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $28,597
Total amount of fees paid to insurance company	USD $27,431
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,597
Amount paid for insurance broker fees	27431
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	93
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,071
Total amount of fees paid to insurance company	USD $257
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,071
Amount paid for insurance broker fees	257
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	281
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,083
Total amount of fees paid to insurance company	USD $226
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,083
Amount paid for insurance broker fees	226
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

847733

Policy instance

Insurance contract or identification number	847733
Number of Individuals Covered	405
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,910
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,929,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,910
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	232
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	281
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,859
Total amount of fees paid to insurance company	USD $266
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,859
Amount paid for insurance broker fees	266
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $140
Total amount of fees paid to insurance company	USD $14
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,967
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
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	SUMMA INSURANCE AGENCY LLC

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

Policy contract number

755310

Policy instance

Insurance contract or identification number	755310
Number of Individuals Covered	414
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of fees paid to insurance company	USD $77,166
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,825,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	77166
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES CORP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	150
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,730
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,730
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	238
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	568
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $8,154
Total amount of fees paid to insurance company	USD $980
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	980
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $8,154
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	431
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $6,010
Total amount of fees paid to insurance company	USD $883
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $30,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,010
Insurance broker organization code?	3
Amount paid for insurance broker fees	883
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	584
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,466
Total amount of fees paid to insurance company	USD $980
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	980
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $6,466
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	568
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,599
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $22,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,599
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	146
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,470
Total amount of fees paid to insurance company	USD $1,184
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	Yes
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 $29,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,470
Insurance broker organization code?	3
Amount paid for insurance broker fees	1184
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	250
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00171150

Policy instance

Insurance contract or identification number	00171150
Number of Individuals Covered	267
Total amount of commissions paid to insurance broker	USD $17,466
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,466
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

0026445-01

Policy instance

Insurance contract or identification number	0026445-01
Number of Individuals Covered	267
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $85,376
Total amount of fees paid to insurance company	USD $37,202
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	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,376
Amount paid for insurance broker fees	37202
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	14
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $150
Total amount of fees paid to insurance company	USD $17
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $77
Amount paid for insurance broker fees	17
Insurance broker organization code?	3
Insurance broker name	BRYAN M. TATE

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00171150

Policy instance

Insurance contract or identification number	00171150
Number of Individuals Covered	261
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $54,950
Total amount of fees paid to insurance company	USD $5,520
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,850,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,950
Amount paid for insurance broker fees	5520
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	210
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,464
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,464
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	401
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $5,764
Total amount of fees paid to insurance company	USD $663
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $30,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	663
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $5,764
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	255
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	234
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $6,231
Total amount of fees paid to insurance company	USD $969
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	969
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $6,231
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	175
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,163
Total amount of fees paid to insurance company	USD $853
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION EYE CARE CENTER INC. (National Association of Insurance Commissioners NAIC id number: 44613 )

Policy contract number

220

Policy instance

Insurance contract or identification number	220
Number of Individuals Covered	284
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	296
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,125
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00169412

Policy instance

Insurance contract or identification number	00169412
Number of Individuals Covered	302
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $16,220
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $498,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	268
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	15
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $181
Total amount of fees paid to insurance company	USD $21
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	393
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,162
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION EYE CARE CENTER INC. (National Association of Insurance Commissioners NAIC id number: 44613 )

Policy contract number

220

Policy instance

Insurance contract or identification number	220
Number of Individuals Covered	305
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

0010411-01

Policy instance

Insurance contract or identification number	0010411-01
Number of Individuals Covered	318
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $76,716
Total amount of fees paid to insurance company	USD $53,486
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,716
Amount paid for insurance broker fees	29512
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	TALUS BROKERAGE SERVICES LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010076978

Policy instance

Insurance contract or identification number	000010076978
Number of Individuals Covered	175
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,689
Total amount of fees paid to insurance company	USD $1,896
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,689
Amount paid for insurance broker fees	1896
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	BEHNKE AGENCY OF OHIO

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00169412

Policy instance

Insurance contract or identification number	00169412
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,399
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $6,399
Insurance broker name	BEHNKE AGENCY OF OHIO

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-384014

Policy instance

Insurance contract or identification number	010-384014
Number of Individuals Covered	268
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7788144

Policy instance

Insurance contract or identification number	E7788144
Number of Individuals Covered	19
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $246
Total amount of fees paid to insurance company	USD $15
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112
Amount paid for insurance broker fees	13
Insurance broker organization code?	3
Insurance broker name	BRYAN M. TATE

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118117

Policy instance

Insurance contract or identification number	000010118117
Number of Individuals Covered	396
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $5,946
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,946
Insurance broker organization code?	3
Insurance broker name	BEHNKE AGENCY OF OHIO

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010118116

Policy instance

Insurance contract or identification number	000010118116
Number of Individuals Covered	431
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $2,708
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,708
Insurance broker organization code?	3
Insurance broker name	BEHNKE AGENCY OF OHIO

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Company Name:	THE MONTEFIORE HOME INC.
Employer identification number (EIN):	340714360
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities