401k Plan data: ALTIUM PACKAGING LP GROUP WELFARE PLAN plan

ALTIUM PACKAGING LP GROUP WELFARE PLAN 401k Plan overview

Plan Name	ALTIUM PACKAGING LP GROUP WELFARE PLAN
Plan identification number	501

ALTIUM PACKAGING LP GROUP WELFARE 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 Other welfare benefit cover

401k Sponsoring company profile

ALTIUM PACKAGING LP has sponsored the creation of one or more 401k plans.

Company Name: ALTIUM PACKAGING LP

Employer identification number (EIN): 061056158

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ALTIUM PACKAGING LP GROUP WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 BETH DUNCAN 2023-06-22
501 2021-01-01 BETH DUNCAN 2022-05-09
501 2020-01-01 BETH DUNCAN 2021-09-14
501 2019-01-01
501 2018-01-01
501 2017-01-01 PAM KIRBY RICHARD SEHRING 2018-10-12
501 2016-01-01 BETH DUNCAN RICHARD SEHRING 2017-10-11
501 2015-01-01 BETH DUNCAN RICHARD SEHRING 2016-10-12
501 2014-01-01 SONDRA DOWDELL RICHARD SEHRING 2015-10-15
501 2013-01-01 DEANA NILSEN RICHARD SEHRING 2014-10-14
501 2012-01-01 DEANA NILSEN RICHARD SEHRING 2013-10-15
501 2011-01-01 KIMBERLY A. HOOVER RICHARD SEHRING 2012-09-26
501 2010-01-01 KIMBERLY A. HOOVER RICHARD SEHRING 2011-10-14
501 2009-01-01 KIMBERLY A. HOOVER RICHARD SEHRING 2010-10-14
501 2009-01-01 KIMBERLY A. HOOVER RICHARD SEHRING 2010-10-14
501 2009-01-01 KIMBERLY A. HOOVER RICHARD SEHRING 2010-10-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	BETH DUNCAN	2023-06-22
501	2021-01-01	BETH DUNCAN	2022-05-09
501	2020-01-01	BETH DUNCAN	2021-09-14
501	2019-01-01
501	2018-01-01
501	2017-01-01	PAM KIRBY		RICHARD SEHRING	2018-10-12
501	2016-01-01	BETH DUNCAN		RICHARD SEHRING	2017-10-11
501	2015-01-01	BETH DUNCAN		RICHARD SEHRING	2016-10-12
501	2014-01-01	SONDRA DOWDELL		RICHARD SEHRING	2015-10-15
501	2013-01-01	DEANA NILSEN		RICHARD SEHRING	2014-10-14
501	2012-01-01	DEANA NILSEN		RICHARD SEHRING	2013-10-15
501	2011-01-01	KIMBERLY A. HOOVER		RICHARD SEHRING	2012-09-26
501	2010-01-01	KIMBERLY A. HOOVER		RICHARD SEHRING	2011-10-14
501	2009-01-01	KIMBERLY A. HOOVER		RICHARD SEHRING	2010-10-14
501	2009-01-01	KIMBERLY A. HOOVER		RICHARD SEHRING	2010-10-14
501	2009-01-01	KIMBERLY A. HOOVER		RICHARD SEHRING	2010-10-14

Plan Statistics for ALTIUM PACKAGING LP GROUP WELFARE PLAN

401k plan membership statisitcs for ALTIUM PACKAGING LP GROUP WELFARE PLAN

Measure Date Value
2022: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,231
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,167
Number of retired or separated participants receiving benefits 2022-01-01 21
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 2,188
2021: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,674
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,862
Number of retired or separated participants receiving benefits 2021-01-01 11
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 2,873
2020: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,668
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,760
Number of retired or separated participants receiving benefits 2020-01-01 12
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 2,772
2019: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,366
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,338
Number of retired or separated participants receiving benefits 2019-01-01 14
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 2,352
2018: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,311
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,361
Number of retired or separated participants receiving benefits 2018-01-01 5
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 2,366
2017: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,323
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,311
Number of retired or separated participants receiving benefits 2017-01-01 8
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 2,319
2016: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,746
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,311
Number of retired or separated participants receiving benefits 2016-01-01 12
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 2,323
2015: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 3,629
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,738
Number of retired or separated participants receiving benefits 2015-01-01 8
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 1,746
2014: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 3,579
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 3,629
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 3,629
2013: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 3,676
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 3,579
Total of all active and inactive participants 2013-01-01 3,579
2012: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,645
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 3,676
Number of retired or separated participants receiving benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 3,676
2011: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,793
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,645
Number of retired or separated participants receiving benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 1,645
2010: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 2,283
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,793
Number of retired or separated participants receiving benefits 2010-01-01 6
Total of all active and inactive participants 2010-01-01 1,799
2009: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 2,531
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 2,276
Number of retired or separated participants receiving benefits 2009-01-01 7
Total of all active and inactive participants 2009-01-01 2,283

Measure	Date	Value
2022: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,231
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,167
Number of retired or separated participants receiving benefits	2022-01-01	21
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	2,188
2021: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,674
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,862
Number of retired or separated participants receiving benefits	2021-01-01	11
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	2,873
2020: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,668
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,760
Number of retired or separated participants receiving benefits	2020-01-01	12
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	2,772
2019: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,366
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,338
Number of retired or separated participants receiving benefits	2019-01-01	14
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	2,352
2018: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,311
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,361
Number of retired or separated participants receiving benefits	2018-01-01	5
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	2,366
2017: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,323
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,311
Number of retired or separated participants receiving benefits	2017-01-01	8
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	2,319
2016: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,746
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,311
Number of retired or separated participants receiving benefits	2016-01-01	12
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	2,323
2015: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,629
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,738
Number of retired or separated participants receiving benefits	2015-01-01	8
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	1,746
2014: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	3,579
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	3,629
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	3,629
2013: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	3,676
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	3,579
Total of all active and inactive participants	2013-01-01	3,579
2012: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,645
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	3,676
Number of retired or separated participants receiving benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	3,676
2011: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,793
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,645
Number of retired or separated participants receiving benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	1,645
2010: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	2,283
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,793
Number of retired or separated participants receiving benefits	2010-01-01	6
Total of all active and inactive participants	2010-01-01	1,799
2009: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	2,531
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	2,276
Number of retired or separated participants receiving benefits	2009-01-01	7
Total of all active and inactive participants	2009-01-01	2,283

Form 5500 Responses for ALTIUM PACKAGING LP GROUP WELFARE PLAN

2022: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan 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
2010: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ALTIUM PACKAGING LP GROUP WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
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

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

Policy contract number

804825G

Policy instance

Insurance contract or identification number	804825G
Number of Individuals Covered	3131
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $14,045
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ADD
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 $987,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	14045
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

13753994

Policy instance

Insurance contract or identification number	13753994
Number of Individuals Covered	1161
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $342,192
Total amount of fees paid to insurance company	USD $65,257
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
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 $378,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $323,143
Amount paid for insurance broker fees	64233
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

03686

Policy instance

Insurance contract or identification number	03686
Number of Individuals Covered	335
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,078
Total amount of fees paid to insurance company	USD $560
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,078
Amount paid for insurance broker fees	560
Additional information about fees paid to insurance broker	CONSULTING FEES
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

03685

Policy instance

Insurance contract or identification number	03685
Number of Individuals Covered	3779
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,412
Total amount of fees paid to insurance company	USD $6,454
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,412
Amount paid for insurance broker fees	6454
Additional information about fees paid to insurance broker	CONSULTING FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12243474

Policy instance

Insurance contract or identification number	12243474
Number of Individuals Covered	2041
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

938414

Policy instance

Insurance contract or identification number	938414
Number of Individuals Covered	2245
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $110,676
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	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 $1,683,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,784
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

688741

Policy instance

Insurance contract or identification number	688741
Number of Individuals Covered	1023
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $93,045
Total amount of fees paid to insurance company	USD $8,137
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	GRP ACCIDENT
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 $148,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,815
Amount paid for insurance broker fees	7957
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

690193

Policy instance

Insurance contract or identification number	690193
Number of Individuals Covered	1276
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $294,254
Total amount of fees paid to insurance company	USD $30,799
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	CRITICAL ILLNESS
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 $462,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $278,017
Amount paid for insurance broker fees	30252
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

R0832873

Policy instance

Insurance contract or identification number	R0832873
Number of Individuals Covered	25
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,115
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
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 $10,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,603
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	371
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,043
Total amount of fees paid to insurance company	USD $542
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,043
Amount paid for insurance broker fees	542
Additional information about fees paid to insurance broker	CONSULTING FEES
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	3993
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,145
Total amount of fees paid to insurance company	USD $6,315
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,145
Amount paid for insurance broker fees	6315
Additional information about fees paid to insurance broker	CONSULTING FEES
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68783-9

Policy instance

Insurance contract or identification number	68783-9
Number of Individuals Covered	2412
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $33,088
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
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 $417,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,453
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12243474

Policy instance

Insurance contract or identification number	12243474
Number of Individuals Covered	2032
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

938414

Policy instance

Insurance contract or identification number	938414
Number of Individuals Covered	2196
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $180,165
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	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 $1,355,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $98,272
Insurance broker organization code?	3

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

Policy contract number

804825G

Policy instance

Insurance contract or identification number	804825G
Number of Individuals Covered	3196
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $87,198
Total amount of fees paid to insurance company	USD $17,049
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,052,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,198
Insurance broker organization code?	3
Amount paid for insurance broker fees	17049
Additional information about fees paid to insurance broker	BONUS

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	390
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,496
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,496
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	3831
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,069
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,069
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68783-9

Policy instance

Insurance contract or identification number	68783-9
Number of Individuals Covered	1985
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $58,375
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
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 $431,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,375
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12243474

Policy instance

Insurance contract or identification number	12243474
Number of Individuals Covered	1914
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

804825G

Policy instance

Insurance contract or identification number	804825G
Number of Individuals Covered	2814
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $87,198
Total amount of fees paid to insurance company	USD $5,125
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $731,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,198
Insurance broker organization code?	3
Amount paid for insurance broker fees	5125
Additional information about fees paid to insurance broker	BONUS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

938414

Policy instance

Insurance contract or identification number	938414
Number of Individuals Covered	2071
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $157,425
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	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 $1,713,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,868
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	358
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,087
Total amount of fees paid to insurance company	USD $7,627
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7062
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $1,087

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	3350
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,945
Total amount of fees paid to insurance company	USD $69,814
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	64643
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $9,945

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

Policy contract number

0473698

Policy instance

Insurance contract or identification number	0473698
Number of Individuals Covered	2405
Insurance policy start date	2019-01-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $5,791
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $626,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,791
Additional information about fees paid to insurance broker	COMMISIONS
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

ACC / CI / EXRK

Policy instance

Insurance contract or identification number	ACC / CI / EXRK
Number of Individuals Covered	2121
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $151,702
Total amount of fees paid to insurance company	USD $77,031
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INDIVIDUAL EXCESS RISK
Welfare Benefit Premiums Paid to Carrier	USD $1,657,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130,864
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	77031

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12243474

Policy instance

Insurance contract or identification number	12243474
Number of Individuals Covered	1586
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $21,183
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	21183
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

A1377

Policy instance

Insurance contract or identification number	A1377
Number of Individuals Covered	2335
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $9,885
Welfare Benefit Premiums Paid to Carrier	USD $3,620,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9885
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5

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

Policy contract number

804825G

Policy instance

Insurance contract or identification number	804825G
Number of Individuals Covered	2407
Insurance policy start date	2019-11-01
Insurance policy end date	2019-12-31
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	390
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,191
Total amount of fees paid to insurance company	USD $8,361
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7742
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $1,191

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	3097
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,155
Total amount of fees paid to insurance company	USD $64,298
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	59537
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $9,155

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

Policy contract number

0473698

Policy instance

Insurance contract or identification number	0473698
Number of Individuals Covered	2280
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $84,630
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $802,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80,022
Additional information about fees paid to insurance broker	COMMISIONS
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

ACC / CI / EXRK

Policy instance

Insurance contract or identification number	ACC / CI / EXRK
Number of Individuals Covered	1680
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $222,087
Total amount of fees paid to insurance company	USD $828,461
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INDIVIDUAL EXCESS RISK
Welfare Benefit Premiums Paid to Carrier	USD $1,255,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,896
Amount paid for insurance broker fees	801694
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

30043247

Policy instance

Insurance contract or identification number	30043247
Number of Individuals Covered	1343
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,331
Total amount of fees paid to insurance company	USD $45,960
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $153,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	45960
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $15,331

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

A1377

Policy instance

Insurance contract or identification number	A1377
Number of Individuals Covered	2125
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $13,450
Welfare Benefit Premiums Paid to Carrier	USD $4,599,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	13450
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	391
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,695
Total amount of fees paid to insurance company	USD $8,219
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	8219
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $1,260
Insurance broker name	INTEGRO USA INC

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

Policy contract number

0473698

Policy instance

Insurance contract or identification number	0473698
Number of Individuals Covered	2257
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $96,344
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $618,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,158
Additional information about fees paid to insurance broker	COMMISIONS
Insurance broker organization code?	3
Insurance broker name	INTEGRO USA INC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2489
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,800
Total amount of fees paid to insurance company	USD $57,144
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	57144
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $8,818
Insurance broker name	INTEGRO USA INC

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

ACC / CI / EXRK

Policy instance

Insurance contract or identification number	ACC / CI / EXRK
Number of Individuals Covered	1694
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $213,977
Total amount of fees paid to insurance company	USD $747,843
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INDIVIDUAL EXCESS RISK
Welfare Benefit Premiums Paid to Carrier	USD $1,037,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,756
Amount paid for insurance broker fees	734135
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Insurance broker name	BENEFIT ADVISORS SERVICES GROUP LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

30043247

Policy instance

Insurance contract or identification number	30043247
Number of Individuals Covered	1302
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $14,739
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,759
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	INTEGRO USA INC

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

Policy instance

Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Welfare Benefit Premiums Paid to Carrier	USD $3,094,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GS389045283502

Policy instance

Insurance contract or identification number	GS389045283502
Number of Individuals Covered	46
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $919
Other welfare benefits provided	NEW YORK STATUTORY
Welfare Benefit Premiums Paid to Carrier	USD $8,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $364
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	C & H FINANCIAL LLC

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2319
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,615
Total amount of fees paid to insurance company	USD $65
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,185
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	65
Insurance broker name	C & H FINANCIAL LLC

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

Policy instance

Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Welfare Benefit Premiums Paid to Carrier	USD $2,647,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	444
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,865
Total amount of fees paid to insurance company	USD $984
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,437
Amount paid for insurance broker fees	984
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	C & H FINANCIAL LLC

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829802

Policy instance

Insurance contract or identification number	PD385028829802
Number of Individuals Covered	2336
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,090
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $44,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,502
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	C & H FINANCIAL LLC

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2393
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $58,233
Total amount of fees paid to insurance company	USD $4,088
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $537,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,733
Amount paid for insurance broker fees	4088
Additional information about fees paid to insurance broker	COMMISSIONS ON INSURANCE POLICIES ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	C& H FINANCIAL LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2830
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,786
Total amount of fees paid to insurance company	USD $59,438
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,734
Amount paid for insurance broker fees	59438
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	C & H FINANCIAL LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	451
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,584
Total amount of fees paid to insurance company	USD $8,821
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $685
Amount paid for insurance broker fees	8821
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	C & H FINANCIAL LLC

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: 54121 )

Policy contract number

Policy instance

Number of Individuals Covered	211
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,385
Total amount of fees paid to insurance company	USD $39,762
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $39,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,385
Amount paid for insurance broker fees	39762
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS COBRA FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2192
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,126
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,126
Additional information about fees paid to insurance broker	COMMISSIONS & ADMINISTRATIVE SERV.
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	511
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,691
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,691
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

211808

Policy instance

Insurance contract or identification number	211808
Number of Individuals Covered	1795
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $35,870
Welfare Benefit Premiums Paid to Carrier	USD $518,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,591
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLARITY BENEFIT CONSULTING

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

Policy instance

Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Welfare Benefit Premiums Paid to Carrier	USD $2,690,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: 54121 )

Policy contract number

Policy instance

Number of Individuals Covered	219
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,280
Total amount of fees paid to insurance company	USD $25,741
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $25,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,280
Amount paid for insurance broker fees	25741
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS COBRA FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2402
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,023
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $43,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,023
Additional information about fees paid to insurance broker	LEAVE SERVICES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2977
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,510
Total amount of fees paid to insurance company	USD $58,985
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,510
Amount paid for insurance broker fees	58985
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	450
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,360
Total amount of fees paid to insurance company	USD $8,447
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,360
Amount paid for insurance broker fees	8447
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2272
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $58,698
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $533,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,698
Additional information about fees paid to insurance broker	COMMISSIONS ON INSURANCE POLICIES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GS389045283502

Policy instance

Insurance contract or identification number	GS389045283502
Number of Individuals Covered	49
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,029
Other welfare benefits provided	NEW YORK STATUTORY
Welfare Benefit Premiums Paid to Carrier	USD $9,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,029
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2139
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $57,796
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $499,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,796
Additional information about fees paid to insurance broker	COMMISSIONS ON INSURANCE POLICIES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2151
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,705
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $40,628
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
Additional information about fees paid to insurance broker	LEAVE SERVICES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	721
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,231
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,231
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

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

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	1120
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,603
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,603
Additional information about fees paid to insurance broker	MARKETING
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2059
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,290
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,290
Additional information about fees paid to insurance broker	COMMISSIONS & ADMINISTRATIVE SERV.
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GS389045283502

Policy instance

Insurance contract or identification number	GS389045283502
Number of Individuals Covered	56
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,008
Other welfare benefits provided	NEW YORK STATUTORY
Welfare Benefit Premiums Paid to Carrier	USD $10,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,008
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

211808

Policy instance

Insurance contract or identification number	211808
Number of Individuals Covered	1642
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $31,931
Welfare Benefit Premiums Paid to Carrier	USD $456,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,561
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLARITY BENEFIT CONSULTING

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

Policy instance

Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,811,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: 54121 )

Policy contract number

Policy instance

Number of Individuals Covered	180
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,059
Total amount of fees paid to insurance company	USD $21,404
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $21,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,059
Amount paid for insurance broker fees	21404
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS COBRA FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	487
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,443
Total amount of fees paid to insurance company	USD $8,629
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,443
Amount paid for insurance broker fees	8629
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2828
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,511
Total amount of fees paid to insurance company	USD $50,906
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,511
Amount paid for insurance broker fees	50906
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2092
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,743
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $37,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,743
Additional information about fees paid to insurance broker	LEAVE SERVICES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

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

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	1138
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $16,531
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,531
Additional information about fees paid to insurance broker	MARKETING
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2023
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,707
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,707
Additional information about fees paid to insurance broker	COMMISSIONS & ADMINISTRATIVE SERV.
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

211808

Policy instance

Insurance contract or identification number	211808
Number of Individuals Covered	1584
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $35,498
Welfare Benefit Premiums Paid to Carrier	USD $343,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,174
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CLARITY BENEFIT CONSULTING

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GS385028829801

Policy instance

Insurance contract or identification number	GS385028829801
Number of Individuals Covered	59
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $953
Other welfare benefits provided	NEW YORK STATUTORY
Welfare Benefit Premiums Paid to Carrier	USD $9,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $953
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 )

Policy contract number

Policy instance

Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,873,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: 54121 )

Policy contract number

Policy instance

Number of Individuals Covered	159
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $989
Total amount of fees paid to insurance company	USD $20,268
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $20,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $989
Amount paid for insurance broker fees	20268
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS COBRA FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	742
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,574
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,574
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2104
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $49,116
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $468,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,116
Additional information about fees paid to insurance broker	COMMISSIONS ON INSURANCE POLICIES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2924
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,847
Total amount of fees paid to insurance company	USD $46,937
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,847
Amount paid for insurance broker fees	46937
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	556
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,495
Total amount of fees paid to insurance company	USD $8,940
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,495
Amount paid for insurance broker fees	8940
Additional information about fees paid to insurance broker	INSURANCE POLICY COMMISSIONS ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	2767
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,389
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	594
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	738
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $14,514
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2040
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $56,798
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $491,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	1954
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,175
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $38,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GS385028829801

Policy instance

Insurance contract or identification number	GS385028829801
Number of Individuals Covered	52
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $960
Other welfare benefits provided	NEW YORK STATUTORY
Welfare Benefit Premiums Paid to Carrier	USD $9,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1023268001

Policy instance

Insurance contract or identification number	1023268001
Number of Individuals Covered	5261
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $50,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

211808

Policy instance

Insurance contract or identification number	211808
Number of Individuals Covered	1557
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $50,758
Welfare Benefit Premiums Paid to Carrier	USD $390,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	1954
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,906
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	1023
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $16,920
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1023268001

Policy instance

Insurance contract or identification number	1023268001
Number of Individuals Covered	5701
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,683
Insurance broker name	ALLIANT INSURANCE SERVICES HOU

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03686

Policy instance

Insurance contract or identification number	44-03686
Number of Individuals Covered	757
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,493
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

44-03685

Policy instance

Insurance contract or identification number	44-03685
Number of Individuals Covered	3213
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,827
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,827
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA385028829801

Policy instance

Insurance contract or identification number	SA385028829801
Number of Individuals Covered	2106
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $45,686
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $454,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,686
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2106
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,173
Other welfare benefits provided	ADMINISTRATIVE SERVICES ONLY SHOR
Welfare Benefit Premiums Paid to Carrier	USD $51,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,173
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF385028829801

Policy instance

Insurance contract or identification number	GF385028829801
Number of Individuals Covered	783
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,682
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,682
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

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

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	1070
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $17,819
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,819
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

211808

Policy instance

Insurance contract or identification number	211808
Number of Individuals Covered	1782
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $94,868
Welfare Benefit Premiums Paid to Carrier	USD $498,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,898
Insurance broker organization code?	3
Insurance broker name	CLARITY BENEFIT CONSULTING

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

PD385028829801

Policy instance

Insurance contract or identification number	PD385028829801
Number of Individuals Covered	2256
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,909
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $42,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,909
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES

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Company Name:	ALTIUM PACKAGING LP
Employer identification number (EIN):	061056158
NAIC Classification:	326100