401k Plan data: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN plan

TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 401k Plan overview

Plan Name	TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN
Plan identification number	501

TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN Benefits

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

401k Sponsoring company profile

TRI-COUNTY MENTAL HEALTH SERVICES has sponsored the creation of one or more 401k plans.

Company Name: TRI-COUNTY MENTAL HEALTH SERVICES

Employer identification number (EIN): 010316813

NAIC Classification: 621420
NAIC Description: Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01 JEFFREY RAAB 2023-12-11
501 2021-01-01 JEFFREY RAAB 2022-11-10
501 2020-01-01 JEFFREY RAAB 2021-09-27
501 2019-01-01 CATHERINE R. RYDER 2020-10-14
501 2018-01-01 CATHERINE R. RYDER 2019-10-09
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 CATHERINE R. RYDER
501 2011-01-01 CATHERINE R. RYDER
501 2009-01-01 CHRISTOPHER P. COPELAND

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-07-01	JEFFREY RAAB	2023-12-11
501	2021-01-01	JEFFREY RAAB	2022-11-10
501	2020-01-01	JEFFREY RAAB	2021-09-27
501	2019-01-01	CATHERINE R. RYDER	2020-10-14
501	2018-01-01	CATHERINE R. RYDER	2019-10-09
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	CATHERINE R. RYDER
501	2011-01-01	CATHERINE R. RYDER
501	2009-01-01	CHRISTOPHER P. COPELAND

Plan Statistics for TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN

401k plan membership statisitcs for TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN

Measure Date Value
2022: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 119
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 119
Number of retired or separated participants receiving benefits 2022-07-01 0
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 119
2021: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 128
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 128
2020: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 138
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 138
2019: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 181
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 181
2018: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 239
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 212
Total of all active and inactive participants 2018-01-01 212
2017: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 239
Total of all active and inactive participants 2017-01-01 239
2016: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 256
Total of all active and inactive participants 2016-01-01 256
2015: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 256
Total of all active and inactive participants 2015-01-01 256
2014: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 220
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 256
Total of all active and inactive participants 2014-01-01 256
2013: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 209
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 220
Total of all active and inactive participants 2013-01-01 220
2012: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 209
Total of all active and inactive participants 2012-01-01 209
2011: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 234
Total of all active and inactive participants 2011-01-01 234
2009: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 304
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 295
Number of retired or separated participants receiving benefits 2009-01-01 3
Total of all active and inactive participants 2009-01-01 298

Measure	Date	Value
2022: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	119
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	119
Number of retired or separated participants receiving benefits	2022-07-01	0
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	119
2021: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	128
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	128
2020: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	138
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	138
2019: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	181
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	181
2018: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	239
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	212
Total of all active and inactive participants	2018-01-01	212
2017: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	239
Total of all active and inactive participants	2017-01-01	239
2016: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	256
Total of all active and inactive participants	2016-01-01	256
2015: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	256
Total of all active and inactive participants	2015-01-01	256
2014: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	220
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	256
Total of all active and inactive participants	2014-01-01	256
2013: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	209
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	220
Total of all active and inactive participants	2013-01-01	220
2012: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	209
Total of all active and inactive participants	2012-01-01	209
2011: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	234
Total of all active and inactive participants	2011-01-01	234
2009: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	295
Number of retired or separated participants receiving benefits	2009-01-01	3
Total of all active and inactive participants	2009-01-01	298

Form 5500 Responses for TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN

2022: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: TRI-COUNTY MENTAL HEALTH SERVICES WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

915095

Policy instance

Insurance contract or identification number	915095
Number of Individuals Covered	176
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $8,701
Total amount of fees paid to insurance company	USD $3,684
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBER.
Welfare Benefit Premiums Paid to Carrier	USD $88,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,766
Insurance broker organization code?	3
Amount paid for insurance broker fees	3684
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

915097

Policy instance

Insurance contract or identification number	915097
Number of Individuals Covered	119
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $4,505
Total amount of fees paid to insurance company	USD $3,506
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,735
Insurance broker organization code?	3
Amount paid for insurance broker fees	3506
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

915096

Policy instance

Insurance contract or identification number	915096
Number of Individuals Covered	81
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $3,412
Total amount of fees paid to insurance company	USD $889
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBER.
Welfare Benefit Premiums Paid to Carrier	USD $21,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,866
Insurance broker organization code?	3
Amount paid for insurance broker fees	889
Temporary Disability Insurance Welfare Benefit	Yes

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

915095

Policy instance

Insurance contract or identification number	915095
Number of Individuals Covered	176
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $8,701
Total amount of fees paid to insurance company	USD $3,684
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,766
Insurance broker organization code?	3
Amount paid for insurance broker fees	3684
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

915097

Policy instance

Insurance contract or identification number	915097
Number of Individuals Covered	119
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $4,505
Total amount of fees paid to insurance company	USD $3,506
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,735
Insurance broker organization code?	3
Amount paid for insurance broker fees	3506
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-015506-000

Policy instance

Insurance contract or identification number	16-015506-000
Number of Individuals Covered	109
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of fees paid to insurance company	USD $12,044
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $313,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12044
Additional information about fees paid to insurance broker	FEE AMOUNT
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0011460552

Policy instance

Insurance contract or identification number	0011460552
Number of Individuals Covered	22
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $852
Total amount of fees paid to insurance company	USD $17
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $413
Insurance broker organization code?	3
Amount paid for insurance broker fees	17
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	44
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $2,259
Total amount of fees paid to insurance company	USD $32
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,187
Insurance broker organization code?	3
Amount paid for insurance broker fees	32
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	118
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $62,490
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $287,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	62490
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970689

Policy instance

Insurance contract or identification number	OK970689
Number of Individuals Covered	50
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,254
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,254
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

011460552

Policy instance

Insurance contract or identification number	011460552
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $586
Total amount of fees paid to insurance company	USD $12
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $247
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Amount paid for insurance broker fees	12

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3343302

Policy instance

Insurance contract or identification number	3343302
Number of Individuals Covered	128
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,149
Total amount of fees paid to insurance company	USD $536
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	INDEMNITY CONTRACT
Welfare Benefit Premiums Paid to Carrier	USD $104,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,149
Insurance broker organization code?	3
Amount paid for insurance broker fees	536
Additional information about fees paid to insurance broker	GEBERAL AGENT PAYMENTS

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	50
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,181
Total amount of fees paid to insurance company	USD $11
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $602
Insurance broker organization code?	3
Amount paid for insurance broker fees	11
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK752599

Policy instance

Insurance contract or identification number	LK752599
Number of Individuals Covered	200
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,157
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,157
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	55
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,248
Total amount of fees paid to insurance company	USD $6
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $620
Insurance broker organization code?	3
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

011460552

Policy instance

Insurance contract or identification number	011460552
Number of Individuals Covered	37
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $359
Total amount of fees paid to insurance company	USD $3
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $212
Insurance broker organization code?	3
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970689

Policy instance

Insurance contract or identification number	OK970689
Number of Individuals Covered	50
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $463
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $463
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT962964

Policy instance

Insurance contract or identification number	VDT962964
Number of Individuals Covered	62
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,695
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,695
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	138
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,702
Total amount of fees paid to insurance company	USD $72,958
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $290,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	72958
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $8,702

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3343302

Policy instance

Insurance contract or identification number	3343302
Number of Individuals Covered	133
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,063
Total amount of fees paid to insurance company	USD $728
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,471
Additional information about fees paid to insurance broker	NOT SPECIFIED
Insurance broker organization code?	3
Amount paid for insurance broker fees	478

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909758

Policy instance

Insurance contract or identification number	909758
Number of Individuals Covered	82
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $592
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $592
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909757

Policy instance

Insurance contract or identification number	909757
Number of Individuals Covered	203
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,304
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,304
Insurance broker organization code?	3

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	164
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,789
Total amount of fees paid to insurance company	USD $84,464
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	84464
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $8,789

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

011460552

Policy instance

Insurance contract or identification number	011460552
Number of Individuals Covered	47
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $808
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287
Insurance broker organization code?	3

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

Policy contract number

010-042080

Policy instance

Insurance contract or identification number	010-042080
Number of Individuals Covered	347
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,705
Total amount of fees paid to insurance company	USD $1,951
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,705
Amount paid for insurance broker fees	1951
Additional information about fees paid to insurance broker	NOT SPECIFIED ON SCHEDULE A
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	66
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,037
Insurance broker organization code?	3

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	168
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 $88,569
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $283,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	88569
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	97
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,761
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,766
Insurance broker organization code?	3

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

Policy contract number

010-042080

Policy instance

Insurance contract or identification number	010-042080
Number of Individuals Covered	378
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,583
Total amount of fees paid to insurance company	USD $1,487
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,778
Amount paid for insurance broker fees	1487
Additional information about fees paid to insurance broker	NOT SPECIFIED ON SCHEDULE A
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

011460552

Policy instance

Insurance contract or identification number	011460552
Number of Individuals Covered	60
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,190
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,754
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909758

Policy instance

Insurance contract or identification number	909758
Number of Individuals Covered	139
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $789
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $491
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909757-0002

Policy instance

Insurance contract or identification number	909757-0002
Number of Individuals Covered	102
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $290
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $290
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909757-0001

Policy instance

Insurance contract or identification number	909757-0001
Number of Individuals Covered	262
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,546
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,544
Insurance broker organization code?	3

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	192
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 $100,357
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $287,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	100357
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Insurance broker name	HEALTH PLANS, INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909758

Policy instance

Insurance contract or identification number	909758
Number of Individuals Covered	158
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,462
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,462
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0682922

Policy instance

Insurance contract or identification number	R0682922
Number of Individuals Covered	90
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,577
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,577
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL

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

Policy contract number

010-042080

Policy instance

Insurance contract or identification number	010-042080
Number of Individuals Covered	433
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,818
Total amount of fees paid to insurance company	USD $1,679
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,818
Amount paid for insurance broker fees	1679
Additional information about fees paid to insurance broker	NOT SPECIFIED ON SCHEDULE A
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

011460552

Policy instance

Insurance contract or identification number	011460552
Number of Individuals Covered	54
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,030
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,030
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

909757

Policy instance

Insurance contract or identification number	909757
Number of Individuals Covered	324
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,354
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,354
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	216
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $50,868
Total amount of fees paid to insurance company	USD $122,006
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $339,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	122006
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $32,576
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL 301311

Policy instance

Insurance contract or identification number	VPL 301311
Number of Individuals Covered	175
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,089
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,199
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151420

Policy instance

Insurance contract or identification number	GL 151420
Number of Individuals Covered	372
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,041
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,638
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	322
Insurance policy start date	2015-01-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $9,700
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,890
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

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

Policy contract number

010-042080

Policy instance

Insurance contract or identification number	010-042080
Number of Individuals Covered	475
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,891
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 $75,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,891
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 162903

Policy instance

Insurance contract or identification number	G 162903
Number of Individuals Covered	372
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,407
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,964
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 162903

Policy instance

Insurance contract or identification number	G 162903
Number of Individuals Covered	349
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,769
Total amount of fees paid to insurance company	USD $891
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,769
Amount paid for insurance broker fees	891
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL 301311

Policy instance

Insurance contract or identification number	VPL 301311
Number of Individuals Covered	175
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,118
Total amount of fees paid to insurance company	USD $443
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,118
Amount paid for insurance broker fees	443
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151420

Policy instance

Insurance contract or identification number	GL 151420
Number of Individuals Covered	353
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,875
Total amount of fees paid to insurance company	USD $466
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,875
Amount paid for insurance broker fees	466
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	340
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $19,676
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $163,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,091
Insurance broker organization code?	3
Insurance broker name	BGA INSURANCE AGENCY, INC

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	234
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $50,043
Total amount of fees paid to insurance company	USD $116,479
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $333,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	116479
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $50,043
Insurance broker name	HEALEY & ASSOCIATES, INC.

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

Policy contract number

000010160902

Policy instance

Insurance contract or identification number	000010160902
Number of Individuals Covered	167
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,155
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,252
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

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

Policy contract number

000010160904

Policy instance

Insurance contract or identification number	000010160904
Number of Individuals Covered	317
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,468
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,600
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

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

Policy contract number

000400160903

Policy instance

Insurance contract or identification number	000400160903
Number of Individuals Covered	82
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,366
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $797
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	323
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,904
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,161
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151420

Policy instance

Insurance contract or identification number	GL 151420
Number of Individuals Covered	343
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,865
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,865
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL 301311

Policy instance

Insurance contract or identification number	VPL 301311
Number of Individuals Covered	167
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,774
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,774
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 162903

Policy instance

Insurance contract or identification number	G 162903
Number of Individuals Covered	326
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,566
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,566
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

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

Policy contract number

000010160901

Policy instance

Insurance contract or identification number	000010160901
Number of Individuals Covered	322
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $715
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $415
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	220
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $46,630
Total amount of fees paid to insurance company	USD $108,437
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $276,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	108437
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $22,495
Insurance broker name	HEALTH PLANS, INC.

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

Policy contract number

000010160902

Policy instance

Insurance contract or identification number	000010160902
Number of Individuals Covered	171
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,135
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,068
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

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

Policy contract number

000010160904

Policy instance

Insurance contract or identification number	000010160904
Number of Individuals Covered	321
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,616
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,308
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

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

Policy contract number

000010160901

Policy instance

Insurance contract or identification number	000010160901
Number of Individuals Covered	324
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $508
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	305
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $17,190
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,856
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 178988

Policy instance

Insurance contract or identification number	VG 178988
Number of Individuals Covered	61
Insurance policy start date	2012-01-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,048
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $524
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 138199

Policy instance

Insurance contract or identification number	GL 138199
Number of Individuals Covered	310
Insurance policy start date	2012-02-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $888
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $444
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD112065

Policy instance

Insurance contract or identification number	LTD112065
Number of Individuals Covered	168
Insurance policy start date	2012-01-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,194
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,097
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

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

Policy contract number

000400160903

Policy instance

Insurance contract or identification number	000400160903
Number of Individuals Covered	71
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,178
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $589
Insurance broker organization code?	3
Insurance broker name	HEALEY & ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 156722

Policy instance

Insurance contract or identification number	G 156722
Number of Individuals Covered	306
Insurance policy start date	2012-01-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,734
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,367
Insurance broker organization code?	3
Insurance broker name	BGA FINANCIAL INC

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-201487

Policy instance

Insurance contract or identification number	UNI-201487
Number of Individuals Covered	209
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $41,474
Total amount of fees paid to insurance company	USD $98,986
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	98986
Additional information about fees paid to insurance broker	ADMINISTRATION & UTILIZATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $18,453
Insurance broker name	HEALTH PLANS, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 138199

Policy instance

Insurance contract or identification number	GL 138199
Number of Individuals Covered	315
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD112065

Policy instance

Insurance contract or identification number	LTD112065
Number of Individuals Covered	170
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,508
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 156722

Policy instance

Insurance contract or identification number	G 156722
Number of Individuals Covered	314
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,750
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

LGS00424-10

Policy instance

Insurance contract or identification number	LGS00424-10
Number of Individuals Covered	234
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $42,408
Total amount of fees paid to insurance company	USD $105,287
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	325
Insurance policy start date	2011-07-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $17,896
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 178988

Policy instance

Insurance contract or identification number	VG 178988
Number of Individuals Covered	67
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,208
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 178988

Policy instance

Insurance contract or identification number	VG 178988
Number of Individuals Covered	76
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,302
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060219

Policy instance

Insurance contract or identification number	000060219
Number of Individuals Covered	362
Insurance policy start date	2010-07-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,265
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 138199

Policy instance

Insurance contract or identification number	GL 138199
Number of Individuals Covered	356
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,440
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD112065

Policy instance

Insurance contract or identification number	LTD112065
Number of Individuals Covered	181
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,028
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

QBE INSURANCE (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

LGS00424-10

Policy instance

Insurance contract or identification number	LGS00424-10
Number of Individuals Covered	288
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53,872
Total amount of fees paid to insurance company	USD $120,766
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 156722

Policy instance

Insurance contract or identification number	G 156722
Number of Individuals Covered	355
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,517
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1003997

Policy instance

Insurance contract or identification number	1003997
Number of Individuals Covered	241
Insurance policy start date	2010-01-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $9,237
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TRI-COUNTY MENTAL HEALTH SERVICES
Employer identification number (EIN):	010316813
NAIC Classification:	621420
NAIC Description:	Outpatient Mental Health and Substance Abuse Centers