401k Plan data: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN plan

ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 401k Plan overview

Plan Name	ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN
Plan identification number	501

ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN Benefits

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

401k Sponsoring company profile

ALLIANCE HEALTH, INC. has sponsored the creation of one or more 401k plans.

Company Name: ALLIANCE HEALTH, INC.

Employer identification number (EIN): 043468274

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01 MICHAEL DODOS 2020-01-20
501 2018-01-01
501 2017-01-01 MICHAEL DODOS
501 2016-01-01 MICHAEL DODOS
501 2015-01-01 MICHAEL DODOS
501 2015-01-01 MICHAEL DODOS
501 2014-01-01 PATRICIA MARKLEY
501 2014-01-01 PATRICIA MARKLEY
501 2013-01-01 PATRICIA MARKLEY
501 2012-01-01 PATRICIA MARKLEY
501 2011-01-01 PATRICIA MARKLEY
501 2009-01-01 PATRICIA MARKLEY

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2019-01-01	MICHAEL DODOS	2020-01-20
501	2018-01-01
501	2017-01-01	MICHAEL DODOS
501	2016-01-01	MICHAEL DODOS
501	2015-01-01	MICHAEL DODOS
501	2015-01-01	MICHAEL DODOS
501	2014-01-01	PATRICIA MARKLEY
501	2014-01-01	PATRICIA MARKLEY
501	2013-01-01	PATRICIA MARKLEY
501	2012-01-01	PATRICIA MARKLEY
501	2011-01-01	PATRICIA MARKLEY
501	2009-01-01	PATRICIA MARKLEY

Plan Statistics for ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN

401k plan membership statisitcs for ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN

Measure Date Value
2019: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 305
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
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 0
2018: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 319
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 305
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 305
2017: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 324
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 338
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 338
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 338
2016: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 92
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 88
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 88
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 88
2015: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 92
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 92
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 92
2014: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 139
Total of all active and inactive participants 2014-01-01 139
Total participants 2014-01-01 139
2013: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 99
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 134
Number of retired or separated participants receiving benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 135
Total participants 2013-01-01 135
2012: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 98
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 99
Total participants 2012-01-01 99
2011: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 84
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 88
Total of all active and inactive participants 2011-01-01 88
2009: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 79
Number of retired or separated participants receiving benefits 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 81

Measure	Date	Value
2019: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	305
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
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	0
2018: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	319
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	305
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	305
2017: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	324
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	338
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	338
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	338
2016: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	92
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	88
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	88
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	88
2015: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	92
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	92
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	92
2014: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	139
Total of all active and inactive participants	2014-01-01	139
Total participants	2014-01-01	139
2013: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	99
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	134
Number of retired or separated participants receiving benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	135
Total participants	2013-01-01	135
2012: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	98
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	99
Total participants	2012-01-01	99
2011: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	84
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	88
Total of all active and inactive participants	2011-01-01	88
2009: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	79
Number of retired or separated participants receiving benefits	2009-01-01	2
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	81

Form 5500 Responses for ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN

2019: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
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: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2017: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2016: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2015: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2012: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2011: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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
2009: ALLIANCE HEALTH, INC. CONNECTOR PAYROLL DEDUCTION 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

Insurance Providers Used on plan

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

Policy contract number

00539197

Policy instance

Insurance contract or identification number	00539197
Number of Individuals Covered	318
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $3,629
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $120,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,629
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	74
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $624
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $624
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	70
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $711
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $711
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	74
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,494
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,494
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0078911

Policy instance

Insurance contract or identification number	W0078911
Number of Individuals Covered	35
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $4,701
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $83,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,701
Insurance broker organization code?	3

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

Policy contract number

E3167509

Policy instance

Insurance contract or identification number	E3167509
Number of Individuals Covered	426
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $77,957
Total amount of fees paid to insurance company	USD $20,552
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $306,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,302
Amount paid for insurance broker fees	8324
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

0911275

Policy instance

Insurance contract or identification number	0911275
Number of Individuals Covered	295
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $46,926
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,513,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,926
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083409

Policy instance

Insurance contract or identification number	30083409
Number of Individuals Covered	100
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $227
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $227
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10165911001

Policy instance

Insurance contract or identification number	10165911001
Number of Individuals Covered	64
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	50
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,224
Total amount of fees paid to insurance company	USD $137
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,224
Insurance broker organization code?	3
Amount paid for insurance broker fees	137
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,357
Total amount of fees paid to insurance company	USD $148
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,357
Insurance broker organization code?	3
Amount paid for insurance broker fees	148
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	50
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,558
Total amount of fees paid to insurance company	USD $353
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,558
Insurance broker organization code?	3
Amount paid for insurance broker fees	353
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083409

Policy instance

Insurance contract or identification number	30083409
Number of Individuals Covered	92
Insurance policy start date	2018-06-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $296
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296
Insurance broker organization code?	3

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

Policy contract number

E4053799

Policy instance

Insurance contract or identification number	E4053799
Number of Individuals Covered	85
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $44,533
Total amount of fees paid to insurance company	USD $15,135
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $129,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,399
Amount paid for insurance broker fees	1555
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

E4053781

Policy instance

Insurance contract or identification number	E4053781
Number of Individuals Covered	33
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $20,465
Total amount of fees paid to insurance company	USD $7,206
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $54,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,353
Amount paid for insurance broker fees	792
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

E7965155

Policy instance

Insurance contract or identification number	E7965155
Number of Individuals Covered	100
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $29,380
Total amount of fees paid to insurance company	USD $10,718
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $120,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,787
Amount paid for insurance broker fees	1978
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

E4053773

Policy instance

Insurance contract or identification number	E4053773
Number of Individuals Covered	29
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,797
Total amount of fees paid to insurance company	USD $5,423
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $62,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,627
Amount paid for insurance broker fees	553
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

0911275

Policy instance

Insurance contract or identification number	0911275
Number of Individuals Covered	298
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $118,860
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,959,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118,860
Insurance broker organization code?	3

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

Policy contract number

00539197

Policy instance

Insurance contract or identification number	00539197
Number of Individuals Covered	334
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,033
Total amount of fees paid to insurance company	USD $4,729
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,033
Amount paid for insurance broker fees	4729
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0078911

Policy instance

Insurance contract or identification number	W0078911
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,907
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,907
Insurance broker organization code?	3

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	60
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,301
Total amount of fees paid to insurance company	USD $277
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,301
Amount paid for insurance broker fees	151
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
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 $3,617
Total amount of fees paid to insurance company	USD $662
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,617
Amount paid for insurance broker fees	361
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4956997

Policy instance

Insurance contract or identification number	4956997
Number of Individuals Covered	105
Insurance policy start date	2017-01-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $1,108
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,108
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES (NY) LLC

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0078911

Policy instance

Insurance contract or identification number	W0078911
Number of Individuals Covered	32
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,065
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $211,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,065
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES LLC

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

0160590000

Policy instance

Insurance contract or identification number	0160590000
Number of Individuals Covered	69
Insurance policy start date	2017-01-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $4,034
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $184,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,034
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES (NY) LLC

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

0160600000

Policy instance

Insurance contract or identification number	0160600000
Number of Individuals Covered	7
Insurance policy start date	2017-01-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $442
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $442
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES (NY) LLC

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

Policy contract number

00539197

Policy instance

Insurance contract or identification number	00539197
Number of Individuals Covered	361
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,344
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,344
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES (NY) LLC

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	55
Insurance policy start date	2016-06-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $685
Total amount of fees paid to insurance company	USD $272
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $685
Insurance broker organization code?	3
Amount paid for insurance broker fees	272
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	55
Insurance policy start date	2016-06-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $630
Total amount of fees paid to insurance company	USD $231
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $630
Insurance broker organization code?	3
Amount paid for insurance broker fees	231
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	55
Insurance policy start date	2016-06-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $2,013
Total amount of fees paid to insurance company	USD $597
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,013
Insurance broker organization code?	3
Amount paid for insurance broker fees	597
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	51
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,200
Total amount of fees paid to insurance company	USD $255
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,200
Amount paid for insurance broker fees	139
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

0911275

Policy instance

Insurance contract or identification number	0911275
Number of Individuals Covered	280
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $58,992
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,293,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,992
Insurance broker organization code?	3
Insurance broker name	NFP CORPORATE SERVICES (NY) LLC

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4956997

Policy instance

Insurance contract or identification number	4956997
Number of Individuals Covered	207
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $18,243
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $569,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,243
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	65
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,054
Total amount of fees paid to insurance company	USD $272
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,054
Insurance broker organization code?	3
Amount paid for insurance broker fees	272
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	65
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,177
Total amount of fees paid to insurance company	USD $135
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,177
Insurance broker organization code?	3
Amount paid for insurance broker fees	135
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker name	NFP INSURANCE SERVICES, INC

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	65
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $982
Total amount of fees paid to insurance company	USD $106
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $982
Amount paid for insurance broker fees	106
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	2
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $11,175
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,175
Insurance broker organization code?	3
Insurance broker name	JOHN THORBAHN

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	61
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $3,316
Total amount of fees paid to insurance company	USD $1,266
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	61
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,366
Total amount of fees paid to insurance company	USD $614
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,366
Amount paid for insurance broker fees	614
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	61
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,095
Total amount of fees paid to insurance company	USD $489
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,095
Amount paid for insurance broker fees	489
Insurance broker name	NFP INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	22
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $12,520
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $179,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,520
Insurance broker organization code?	3
Insurance broker name	JOHN THORBAHN

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4956997

Policy instance

Insurance contract or identification number	4956997
Number of Individuals Covered	228
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $2,431
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $619,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,431
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	54
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,638
Total amount of fees paid to insurance company	USD $683
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,115
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
Amount paid for insurance broker fees	480
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

79270000

Policy instance

Insurance contract or identification number	79270000
Number of Individuals Covered	63
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $21,844
Total amount of fees paid to insurance company	USD $7,622
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $608,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,844
Amount paid for insurance broker fees	7622
Insurance broker organization code?	3
Insurance broker name	THORBAHN INSURANCE AGENCY

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	24
Insurance policy start date	2012-06-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $23,377
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $326,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,377
Insurance broker organization code?	3
Insurance broker name	JOHN THORBAHN

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	54
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $769
Total amount of fees paid to insurance company	USD $265
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $769
Amount paid for insurance broker fees	186
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	54
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $978
Total amount of fees paid to insurance company	USD $332
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $978
Amount paid for insurance broker fees	233
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

0004240001

Policy instance

Insurance contract or identification number	0004240001
Number of Individuals Covered	138
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,542
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,542
Insurance broker organization code?	3
Insurance broker name	THORBAHN AND ASSOCIATES INSURANCE A

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

0004240001

Policy instance

Insurance contract or identification number	0004240001
Number of Individuals Covered	123
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,070
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,070
Insurance broker organization code?	3
Insurance broker name	THORBAHN AND ASSOCIATES INSURANCE A

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

79270000

Policy instance

Insurance contract or identification number	79270000
Number of Individuals Covered	60
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $16,727
Total amount of fees paid to insurance company	USD $1,713
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $567,659
Commission paid to Insurance Broker	USD $16,727
Amount paid for insurance broker fees	1713
Insurance broker organization code?	3
Insurance broker name	THORBAHN INSURANCE AGENCY

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	39
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $2,397
Total amount of fees paid to insurance company	USD $407
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,397
Amount paid for insurance broker fees	222
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	39
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $847
Total amount of fees paid to insurance company	USD $191
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $847
Amount paid for insurance broker fees	104
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	39
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $685
Total amount of fees paid to insurance company	USD $165
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $6,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $685
Amount paid for insurance broker fees	90
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	26
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $13,910
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,910
Insurance broker organization code?	3
Insurance broker name	JOHN THORBAHN

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

Policy contract number

G 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	41
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $891
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 $8,098
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 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	41
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $711
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
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $6,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	28
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $12,842
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4955967

Policy instance

Insurance contract or identification number	4955967
Number of Individuals Covered	108
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $16,454
Total amount of fees paid to insurance company	USD $4,896
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 $559,807
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

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	41
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $2,504
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 $16,692
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 157243

Policy instance

Insurance contract or identification number	G 157243
Number of Individuals Covered	36
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $648
Total amount of fees paid to insurance company	USD $194
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 $5,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $648
Amount paid for insurance broker fees	194
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER
Insurance broker organization code?	3
Insurance broker name	THORBAHN & ASSOCIATES INSURANCE AGE

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

453254

Policy instance

Insurance contract or identification number	453254
Number of Individuals Covered	27
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $13,895
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $200,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,895
Insurance broker organization code?	3
Insurance broker name	JOHN THORBAHN

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

Policy contract number

GL 139215

Policy instance

Insurance contract or identification number	GL 139215
Number of Individuals Covered	36
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $548
Total amount of fees paid to insurance company	USD $141
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
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $5,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $548
Amount paid for insurance broker fees	141
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER
Insurance broker organization code?	3
Insurance broker name	THORBAHN & ASSOCIATES INSURANCE AGE

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4955967

Policy instance

Insurance contract or identification number	4955967
Number of Individuals Covered	99
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $16,900
Total amount of fees paid to insurance company	USD $4,398
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 $555,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,900
Amount paid for insurance broker fees	4398
Additional information about fees paid to insurance broker	BONUS AND PERSISTENCY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	THORBAHN & ASSOCIATES

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

Policy contract number

LTD 113163

Policy instance

Insurance contract or identification number	LTD 113163
Number of Individuals Covered	36
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $1,985
Total amount of fees paid to insurance company	USD $438
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 $13,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,985
Amount paid for insurance broker fees	438
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER
Insurance broker organization code?	3
Insurance broker name	THORBAHN & ASSOCIATES INSURANCE AGE

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Company Name:	ALLIANCE HEALTH, INC.
Employer identification number (EIN):	043468274
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities