401k Plan data: GROUP HEALTH INSURANCE PLAN plan

GROUP HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	GROUP HEALTH INSURANCE PLAN
Plan identification number	502

GROUP HEALTH INSURANCE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

CHAPMAN AND CUTLER LLP has sponsored the creation of one or more 401k plans.

Company Name: CHAPMAN AND CUTLER LLP

Employer identification number (EIN): 362153731

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP HEALTH INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01 ELIZABETH ZAMORA 2023-07-24
502 2021-01-01 ELIZABETH ZAMORA 2022-07-26
502 2020-01-01 SHAN GALLOWAY 2021-07-27
502 2019-01-01 SHAN GALLOWAY 2020-10-12
502 2018-01-01
502 2017-01-01
502 2016-01-01 STACEY KIELBASA
502 2015-01-01 GAIL GLYSING
502 2014-01-01 HEATHER BECKER
502 2013-01-01 HEATHER BECKER
502 2012-01-01 JOHN BRINKS
502 2011-01-01 GARY POLEGA
502 2009-01-01 GARY POLEGA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2022-01-01	ELIZABETH ZAMORA	2023-07-24
502	2021-01-01	ELIZABETH ZAMORA	2022-07-26
502	2020-01-01	SHAN GALLOWAY	2021-07-27
502	2019-01-01	SHAN GALLOWAY	2020-10-12
502	2018-01-01
502	2017-01-01
502	2016-01-01	STACEY KIELBASA
502	2015-01-01	GAIL GLYSING
502	2014-01-01	HEATHER BECKER
502	2013-01-01	HEATHER BECKER
502	2012-01-01	JOHN BRINKS
502	2011-01-01	GARY POLEGA
502	2009-01-01	GARY POLEGA

Plan Statistics for GROUP HEALTH INSURANCE PLAN

401k plan membership statisitcs for GROUP HEALTH INSURANCE PLAN

Measure Date Value
2022: GROUP HEALTH INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 308
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 313
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 315
Number of employers contributing to the scheme 2022-01-01 0
2021: GROUP HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 333
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 306
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 308
Number of employers contributing to the scheme 2021-01-01 0
2020: GROUP HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 376
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 321
Number of retired or separated participants receiving benefits 2020-01-01 12
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 333
Number of employers contributing to the scheme 2020-01-01 0
2019: GROUP HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 347
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 374
Number of retired or separated participants receiving benefits 2019-01-01 2
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 376
Number of employers contributing to the scheme 2019-01-01 0
2018: GROUP HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 355
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 336
Number of retired or separated participants receiving benefits 2018-01-01 11
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 347
Number of employers contributing to the scheme 2018-01-01 0
2017: GROUP HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 383
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 339
Number of retired or separated participants receiving benefits 2017-01-01 24
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 363
2016: GROUP HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 348
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 438
Number of retired or separated participants receiving benefits 2016-01-01 13
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 451
2015: GROUP HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 359
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 334
Number of retired or separated participants receiving benefits 2015-01-01 14
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 348
2014: GROUP HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 359
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 351
Number of retired or separated participants receiving benefits 2014-01-01 8
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 359
2013: GROUP HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 357
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 355
Number of retired or separated participants receiving benefits 2013-01-01 4
Total of all active and inactive participants 2013-01-01 359
2012: GROUP HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 343
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 357
Number of retired or separated participants receiving benefits 2012-01-01 9
Total of all active and inactive participants 2012-01-01 366
2011: GROUP HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 393
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 333
Number of retired or separated participants receiving benefits 2011-01-01 10
Total of all active and inactive participants 2011-01-01 343
2009: GROUP HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 424
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 369
Number of retired or separated participants receiving benefits 2009-01-01 24
Number of other retired or separated participants entitled to future benefits 2009-01-01 15
Total of all active and inactive participants 2009-01-01 408
Total participants 2009-01-01 408

Measure	Date	Value
2022: GROUP HEALTH INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	308
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	313
Number of retired or separated participants receiving benefits	2022-01-01	2
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	315
Number of employers contributing to the scheme	2022-01-01	0
2021: GROUP HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	333
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	306
Number of retired or separated participants receiving benefits	2021-01-01	2
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	308
Number of employers contributing to the scheme	2021-01-01	0
2020: GROUP HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	376
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	321
Number of retired or separated participants receiving benefits	2020-01-01	12
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	333
Number of employers contributing to the scheme	2020-01-01	0
2019: GROUP HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	347
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	374
Number of retired or separated participants receiving benefits	2019-01-01	2
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	376
Number of employers contributing to the scheme	2019-01-01	0
2018: GROUP HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	355
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	336
Number of retired or separated participants receiving benefits	2018-01-01	11
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	347
Number of employers contributing to the scheme	2018-01-01	0
2017: GROUP HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	383
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	339
Number of retired or separated participants receiving benefits	2017-01-01	24
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	363
2016: GROUP HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	348
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	438
Number of retired or separated participants receiving benefits	2016-01-01	13
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	451
2015: GROUP HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	359
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	334
Number of retired or separated participants receiving benefits	2015-01-01	14
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	348
2014: GROUP HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	359
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	351
Number of retired or separated participants receiving benefits	2014-01-01	8
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	359
2013: GROUP HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	357
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	355
Number of retired or separated participants receiving benefits	2013-01-01	4
Total of all active and inactive participants	2013-01-01	359
2012: GROUP HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	343
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	357
Number of retired or separated participants receiving benefits	2012-01-01	9
Total of all active and inactive participants	2012-01-01	366
2011: GROUP HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	393
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	333
Number of retired or separated participants receiving benefits	2011-01-01	10
Total of all active and inactive participants	2011-01-01	343
2009: GROUP HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	424
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	369
Number of retired or separated participants receiving benefits	2009-01-01	24
Number of other retired or separated participants entitled to future benefits	2009-01-01	15
Total of all active and inactive participants	2009-01-01	408
Total participants	2009-01-01	408

Form 5500 Responses for GROUP HEALTH INSURANCE PLAN

2022: GROUP HEALTH INSURANCE 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 benefit arrangement – Insurance	Yes
2021: GROUP HEALTH INSURANCE 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 benefit arrangement – Insurance	Yes
2020: GROUP HEALTH INSURANCE 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 benefit arrangement – Insurance	Yes
2019: GROUP HEALTH INSURANCE 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: GROUP HEALTH INSURANCE 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: GROUP HEALTH INSURANCE 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: GROUP HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: GROUP HEALTH INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: GROUP HEALTH INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: GROUP HEALTH INSURANCE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: GROUP HEALTH INSURANCE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: GROUP HEALTH INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: GROUP HEALTH INSURANCE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	246
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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 $35,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	295
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,711
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $316,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $15,711
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	735
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $96,143
Total amount of fees paid to insurance company	USD $3,984
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,418,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $96,143
Amount paid for insurance broker fees	3984
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	719
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $92,565
Total amount of fees paid to insurance company	USD $4,109
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,171,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92,565
Amount paid for insurance broker fees	4109
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS, NON-MONETARY COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	288
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,894
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $298,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,894
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	241
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	243
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	289
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,867
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $319,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $15,867
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	755
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $92,895
Total amount of fees paid to insurance company	USD $4,320
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,307,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $92,895
Amount paid for insurance broker fees	4320
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	764
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $93,532
Total amount of fees paid to insurance company	USD $4,176
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,240,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $93,532
Amount paid for insurance broker fees	4176
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	300
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $15,098
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $302,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $15,098
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	246
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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 $29,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	237
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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 $28,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	281
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $13,676
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $273,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $13,676
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	753
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $91,996
Total amount of fees paid to insurance company	USD $4,224
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,250,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $91,996
Amount paid for insurance broker fees	4224
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	232
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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 $22,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	278
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,462
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $253,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $12,462
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

257045

Policy instance

Insurance contract or identification number	257045
Number of Individuals Covered	745
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $86,143
Total amount of fees paid to insurance company	USD $3,948
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,765,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $86,143
Amount paid for insurance broker fees	3948
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	274
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,676
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $254,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,676
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	760
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $82,254
Total amount of fees paid to insurance company	USD $4,296
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,641,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,254
Amount paid for insurance broker fees	4296
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	214
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	748
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $81,766
Total amount of fees paid to insurance company	USD $3,550
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,542,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,766
Amount paid for insurance broker fees	3550
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20294

Policy instance

Insurance contract or identification number	20294
Number of Individuals Covered	278
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,071
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $220,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,071
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

30043266

Policy instance

Insurance contract or identification number	30043266
Number of Individuals Covered	198
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	748
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $74,360
Total amount of fees paid to insurance company	USD $3,570
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,957,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74,360
Amount paid for insurance broker fees	3570
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

KM05980152

Policy instance

Insurance contract or identification number	KM05980152
Number of Individuals Covered	687
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,665
Total amount of fees paid to insurance company	USD $3,402
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $233,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,665
Insurance broker organization code?	3
Amount paid for insurance broker fees	3402
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	LOCKTON COMPANIES, LLC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	772
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $61,858
Total amount of fees paid to insurance company	USD $3,741
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,946,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,858
Amount paid for insurance broker fees	3741
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

KM05980152

Policy instance

Insurance contract or identification number	KM05980152
Number of Individuals Covered	699
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,591
Total amount of fees paid to insurance company	USD $2,417
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $233,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,591
Insurance broker organization code?	3
Amount paid for insurance broker fees	2417
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	LOCKTON COMPANIES, LLC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	761
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $52,919
Total amount of fees paid to insurance company	USD $5,421
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,240,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05980152

Policy instance

Insurance contract or identification number	KM05980152
Number of Individuals Covered	697
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,545
Total amount of fees paid to insurance company	USD $3,299
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $211,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

084319

Policy instance

Insurance contract or identification number	084319
Number of Individuals Covered	534
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $32,115
Total amount of fees paid to insurance company	USD $4,606
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,579,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,115
Amount paid for insurance broker fees	4606
Insurance broker organization code?	3
Insurance broker name	MESIROW FINANCIAL SERVICES

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

084341

Policy instance

Insurance contract or identification number	084341
Number of Individuals Covered	43
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $2,470
Total amount of fees paid to insurance company	USD $354
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $209,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,470
Amount paid for insurance broker fees	354
Insurance broker organization code?	3
Insurance broker name	MESIROW FINANCIAL SERVICES

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B57045

Policy instance

Insurance contract or identification number	B57045
Number of Individuals Covered	69
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $3,953
Total amount of fees paid to insurance company	USD $567
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $332,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,953
Amount paid for insurance broker fees	567
Insurance broker organization code?	3
Insurance broker name	MESIROW FINANCIAL SERVICES

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

P57045

Policy instance

Insurance contract or identification number	P57045
Number of Individuals Covered	70
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $4,447
Total amount of fees paid to insurance company	USD $638
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $336,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,447
Amount paid for insurance broker fees	638
Insurance broker organization code?	3
Insurance broker name	MESIROW FINANCIAL SERVICES

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

H57045

Policy instance

Insurance contract or identification number	H57045
Number of Individuals Covered	103
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $6,423
Total amount of fees paid to insurance company	USD $921
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $499,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,423
Amount paid for insurance broker fees	921
Insurance broker organization code?	3
Insurance broker name	MESIROW FINANCIAL SERVICES

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

809842

Policy instance

Insurance contract or identification number	809842
Number of Individuals Covered	599
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $29,770
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $296,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,770
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MESIROW INSURANCE SERVICES

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Company Name:	CHAPMAN AND CUTLER LLP
Employer identification number (EIN):	362153731