401k Plan data: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN plan

ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 401k Plan overview

Plan Name	ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN
Plan identification number	501

ELLINGTON MANAGEMENT GROUP, L.L.C. 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

401k Sponsoring company profile

ELLINGTON MANAGEMENT GROUP, LLC. has sponsored the creation of one or more 401k plans.

Company Name: ELLINGTON MANAGEMENT GROUP, LLC.

Employer identification number (EIN): 061441140

NAIC Classification: 523900

Additional information about ELLINGTON MANAGEMENT GROUP, LLC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2015-09-02

Company Identification Number: 0802285742

Legal Registered Office Address: 15950 DALLAS PKWY STE 600

DALLAS
United States of America (USA)
75248

More information about ELLINGTON MANAGEMENT GROUP, LLC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 ROBERT DEBONA
501 2017-01-01 ROBERT DEBONA
501 2016-01-01 ROBERT DEBONA
501 2015-01-01 ROBERT DEBONA
501 2015-01-01 ROBERT DEBONA
501 2014-01-01 JENNIFER WRIGHT
501 2014-01-01 JENNIFER WRIGHT
501 2013-01-01 JENNIFER WRIGHT
501 2012-01-01 JENNIFER WRIGHT
501 2011-01-01 JENNIFER WRIGHT
501 2009-01-01 JENNIFER WRIGHT

Plan Statistics for ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN

401k plan membership statisitcs for ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN

Measure Date Value
2022: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 266
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 294
Total of all active and inactive participants 2022-01-01 294
2021: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 246
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 266
Total of all active and inactive participants 2021-01-01 266
2020: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 250
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 246
Total of all active and inactive participants 2020-01-01 246
2019: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 250
Total of all active and inactive participants 2019-01-01 250
2018: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 259
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 257
Total of all active and inactive participants 2018-01-01 257
2017: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 259
Total of all active and inactive participants 2017-01-01 259
Total participants 2017-01-01 259
2016: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 258
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 261
Total of all active and inactive participants 2016-01-01 261
Total participants 2016-01-01 261
2015: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 246
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 258
Total of all active and inactive participants 2015-01-01 258
Total participants 2015-01-01 258
2014: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 246
Total of all active and inactive participants 2014-01-01 246
Total participants 2014-01-01 246
2013: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 222
Total of all active and inactive participants 2013-01-01 222
Total participants 2013-01-01 222
2012: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 293
Total of all active and inactive participants 2012-01-01 293
Total participants 2012-01-01 293
2011: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 350
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 350
Total of all active and inactive participants 2011-01-01 350
Total participants 2011-01-01 350
2009: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 412
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 412
Total of all active and inactive participants 2009-01-01 412
Total participants 2009-01-01 412

Measure	Date	Value
2022: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	266
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	294
Total of all active and inactive participants	2022-01-01	294
2021: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	266
Total of all active and inactive participants	2021-01-01	266
2020: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	250
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	246
Total of all active and inactive participants	2020-01-01	246
2019: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	250
Total of all active and inactive participants	2019-01-01	250
2018: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	259
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	257
Total of all active and inactive participants	2018-01-01	257
2017: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	259
Total of all active and inactive participants	2017-01-01	259
Total participants	2017-01-01	259
2016: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	258
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	261
Total of all active and inactive participants	2016-01-01	261
Total participants	2016-01-01	261
2015: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	258
Total of all active and inactive participants	2015-01-01	258
Total participants	2015-01-01	258
2014: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	246
Total of all active and inactive participants	2014-01-01	246
Total participants	2014-01-01	246
2013: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	222
Total of all active and inactive participants	2013-01-01	222
Total participants	2013-01-01	222
2012: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	293
Total of all active and inactive participants	2012-01-01	293
Total participants	2012-01-01	293
2011: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	350
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	350
Total of all active and inactive participants	2011-01-01	350
Total participants	2011-01-01	350
2009: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	412
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	412
Total of all active and inactive participants	2009-01-01	412
Total participants	2009-01-01	412

Form 5500 Responses for ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN

2022: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: ELLINGTON MANAGEMENT GROUP, L.L.C. 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 benefit arrangement – Insurance	Yes
2018: ELLINGTON MANAGEMENT GROUP, L.L.C. 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 benefit arrangement – Insurance	Yes
2017: ELLINGTON MANAGEMENT GROUP, L.L.C. 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 benefit arrangement – Insurance	Yes
2016: ELLINGTON MANAGEMENT GROUP, L.L.C. 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 benefit arrangement – Insurance	Yes
2015: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: ELLINGTON MANAGEMENT GROUP, L.L.C. 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 benefit arrangement – Insurance	Yes
2009: ELLINGTON MANAGEMENT GROUP, L.L.C. WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	183
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,188
Total amount of fees paid to insurance company	USD $13,001
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $261,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	13001
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $9,094

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

Policy contract number

611920

Policy instance

Insurance contract or identification number	611920
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,088
Total amount of fees paid to insurance company	USD $2,088
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,088
Insurance broker organization code?	3
Amount paid for insurance broker fees	2088

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	113
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,456
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $920
Insurance broker organization code?	3

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

Policy contract number

608040

Policy instance

Insurance contract or identification number	608040
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $107
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	107
Insurance broker organization code?	3

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

Policy contract number

610824

Policy instance

Insurance contract or identification number	610824
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $419
Life 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	419
Insurance broker organization code?	3

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

Policy contract number

611920

Policy instance

Insurance contract or identification number	611920
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $396
Long Term Disability 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	396
Insurance broker organization code?	3

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	294
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $129,416
Total amount of fees paid to insurance company	USD $60,956
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,728,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,708
Insurance broker organization code?	3
Amount paid for insurance broker fees	60956

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

Policy contract number

608040

Policy instance

Insurance contract or identification number	608040
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,330
Total amount of fees paid to insurance company	USD $583
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,330
Insurance broker organization code?	3
Amount paid for insurance broker fees	583

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

Policy contract number

610824

Policy instance

Insurance contract or identification number	610824
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,272
Total amount of fees paid to insurance company	USD $2,272
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,272
Insurance broker organization code?	3
Amount paid for insurance broker fees	2272

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

Policy contract number

611920

Policy instance

Insurance contract or identification number	611920
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,085
Total amount of fees paid to insurance company	USD $1,547
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,085
Insurance broker organization code?	3
Amount paid for insurance broker fees	1547

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	266
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $114,486
Total amount of fees paid to insurance company	USD $53,937
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,370,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,243
Insurance broker organization code?	3
Amount paid for insurance broker fees	53937

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	167
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,191
Total amount of fees paid to insurance company	USD $8,681
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	8681
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $7,596

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	102
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,189
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $861
Insurance broker organization code?	3

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

Policy contract number

610824

Policy instance

Insurance contract or identification number	610824
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,254
Total amount of fees paid to insurance company	USD $1,567
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,254
Insurance broker organization code?	3
Amount paid for insurance broker fees	1567

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

Policy contract number

608040

Policy instance

Insurance contract or identification number	608040
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $541
Total amount of fees paid to insurance company	USD $225
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $541
Insurance broker organization code?	3
Amount paid for insurance broker fees	225

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

Policy contract number

610824

Policy instance

Insurance contract or identification number	610824
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $973
Total amount of fees paid to insurance company	USD $879
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $973
Insurance broker organization code?	3
Amount paid for insurance broker fees	879

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

Policy contract number

611920

Policy instance

Insurance contract or identification number	611920
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,056
Total amount of fees paid to insurance company	USD $809
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,056
Insurance broker organization code?	3
Amount paid for insurance broker fees	809

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

Policy contract number

608040

Policy instance

Insurance contract or identification number	608040
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $811
Total amount of fees paid to insurance company	USD $402
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $811
Insurance broker organization code?	3
Amount paid for insurance broker fees	402

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

Policy contract number

610824

Policy instance

Insurance contract or identification number	610824
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,698
Total amount of fees paid to insurance company	USD $3,304
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3304
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2,698

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

Policy contract number

608040

Policy instance

Insurance contract or identification number	608040
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,173
Total amount of fees paid to insurance company	USD $720
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,138
Insurance broker organization code?	3
Amount paid for insurance broker fees	720

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	81
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,053
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $781
Insurance broker organization code?	3

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,148
Total amount of fees paid to insurance company	USD $8,961
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $188,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7513
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $6,574

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

Policy contract number

611920

Policy instance

Insurance contract or identification number	611920
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,561
Total amount of fees paid to insurance company	USD $3,383
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,561
Insurance broker organization code?	3
Amount paid for insurance broker fees	3383

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	246
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $61,526
Total amount of fees paid to insurance company	USD $52,138
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,316,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	52138
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $30,763

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

Policy contract number

00544644

Policy instance

Insurance contract or identification number	00544644
Number of Individuals Covered	156
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,587
Total amount of fees paid to insurance company	USD $7,802
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $234,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,587
Amount paid for insurance broker fees	7802
Insurance broker organization code?	3

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	86
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,010
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $756
Insurance broker organization code?	3

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	250
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $62,188
Total amount of fees paid to insurance company	USD $52,699
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,234,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	52699
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $31,094

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	257
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $63,998
Total amount of fees paid to insurance company	USD $54,232
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,215,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	54232
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $31,999

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	87
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,053
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $781
Insurance broker organization code?	3

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

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	159
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $22,807
Total amount of fees paid to insurance company	USD $11,403
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $229,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,404
Insurance broker organization code?	3
Amount paid for insurance broker fees	11403
Insurance broker name	PROFESSIONAL GROUP PLANS, INC.

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

Policy contract number

SGD603050

Policy instance

Insurance contract or identification number	SGD603050
Insurance policy start date	2017-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,026
Total amount of fees paid to insurance company	USD $3,734
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3734
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2,013
Insurance broker name	KABS AGENCY, INC.

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	259
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $64,380
Total amount of fees paid to insurance company	USD $54,557
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $975,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	54557
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $32,190
Insurance broker name	ROBERT E. MUZIKOWSKI

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

Policy contract number

SOK603294

Policy instance

Insurance contract or identification number	SOK603294
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $10,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	82
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,007
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $754
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS

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

Policy contract number

SGM604854

Policy instance

Insurance contract or identification number	SGM604854
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $2,744
Total amount of fees paid to insurance company	USD $2,101
Other welfare benefits provided	BASIC LIFE
Welfare Benefit Premiums Paid to Carrier	USD $43,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2101
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,372
Insurance broker name	ROBERT E. MUZIKOWSKI

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

Policy contract number

SOK603294

Policy instance

Insurance contract or identification number	SOK603294
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $9,944

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

Policy contract number

SGM604854

Policy instance

Insurance contract or identification number	SGM604854
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,304
Total amount of fees paid to insurance company	USD $2,940
Other welfare benefits provided	BASIC LIFE
Welfare Benefit Premiums Paid to Carrier	USD $37,288

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

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	161
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $20,114
Total amount of fees paid to insurance company	USD $10,057
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

30055154

Policy instance

Insurance contract or identification number	30055154
Number of Individuals Covered	73
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $815
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,531

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	258
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $63,406
Total amount of fees paid to insurance company	USD $53,738
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $792,609

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

Policy contract number

SGD603050

Policy instance

Insurance contract or identification number	SGD603050
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $3,944
Total amount of fees paid to insurance company	USD $2,326
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,758

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

Policy contract number

SGD603050

Policy instance

Insurance contract or identification number	SGD603050
Insurance policy start date	2014-02-01
Insurance policy end date	2015-02-01
Total amount of commissions paid to insurance broker	USD $4,226
Total amount of fees paid to insurance company	USD $2,668
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,204

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

Policy contract number

SOK603294

Policy instance

Insurance contract or identification number	SOK603294
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $486
Total amount of fees paid to insurance company	USD $162
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $9,824

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

Policy contract number

SGM604854

Policy instance

Insurance contract or identification number	SGM604854
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,090
Total amount of fees paid to insurance company	USD $454
Other welfare benefits provided	BASIC LIFE
Welfare Benefit Premiums Paid to Carrier	USD $36,841

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

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	158
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $18,581
Total amount of fees paid to insurance company	USD $9,290
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,081

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	246
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $60,648
Total amount of fees paid to insurance company	USD $43,196
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $590,610

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

Policy contract number

SGD603050

Policy instance

Insurance contract or identification number	SGD603050
Insurance policy start date	2013-02-01
Insurance policy end date	2014-02-01
Total amount of commissions paid to insurance broker	USD $3,836
Total amount of fees paid to insurance company	USD $3,175
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,070

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

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,332
Total amount of fees paid to insurance company	USD $7,666
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,418

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	222
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $53,398
Total amount of fees paid to insurance company	USD $40,045
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $549,787

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

Policy contract number

H62061

Policy instance

Insurance contract or identification number	H62061
Number of Individuals Covered	136
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,656
Total amount of fees paid to insurance company	USD $2,041
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,406

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

Policy contract number

SGD603050

Policy instance

Insurance contract or identification number	SGD603050
Number of Individuals Covered	118
Insurance policy start date	2012-02-01
Insurance policy end date	2013-02-01
Total amount of commissions paid to insurance broker	USD $4,579
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	118
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,831
Total amount of fees paid to insurance company	USD $6,915
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

H62061

Policy instance

Insurance contract or identification number	H62061
Number of Individuals Covered	115
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,154
Total amount of fees paid to insurance company	USD $3,370
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	191
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $47,822
Total amount of fees paid to insurance company	USD $23,921
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $416,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

606247

Policy instance

Insurance contract or identification number	606247
Number of Individuals Covered	350
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $47,690
Total amount of fees paid to insurance company	USD $24,855
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $352,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

H62061

Policy instance

Insurance contract or identification number	H62061
Number of Individuals Covered	115
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,357
Total amount of fees paid to insurance company	USD $4,766
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3334354

Policy instance

Insurance contract or identification number	3334354
Number of Individuals Covered	350
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,754
Total amount of fees paid to insurance company	USD $6,877
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $138,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

H62061

Policy instance

Insurance contract or identification number	H62061
Number of Individuals Covered	113
Insurance policy start date	2010-02-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,349
Total amount of fees paid to insurance company	USD $389
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,096
Insurance broker organization code?	3
Amount paid for insurance broker fees	389
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	PROFESSIONAL PENSIONS, INC.

HEALTH NET INSURANCE OF CONNECTICUT (National Association of Insurance Commissioners NAIC id number: 10360 )

Policy contract number

47130P

Policy instance

Insurance contract or identification number	47130P
Number of Individuals Covered	3
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $351
Total amount of fees paid to insurance company	USD $351
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $351
Amount paid for insurance broker fees	351
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

HEALTH NET OF CT (National Association of Insurance Commissioners NAIC id number: 95968 )

Policy contract number

318562

Policy instance

Insurance contract or identification number	318562
Number of Individuals Covered	279
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $75,377
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,226,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,545
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS, INC.

HEALTH NET OF CT (National Association of Insurance Commissioners NAIC id number: 95968 )

Policy contract number

31856C

Policy instance

Insurance contract or identification number	31856C
Number of Individuals Covered	22
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,336
Total amount of fees paid to insurance company	USD $2,051
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,336
Amount paid for insurance broker fees	2051
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

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

Policy contract number

TS05610978

Policy instance

Insurance contract or identification number	TS05610978
Number of Individuals Covered	409
Insurance policy start date	2010-02-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,546
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $134,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,672
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

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

Policy contract number

H62061

Policy instance

Insurance contract or identification number	H62061
Number of Individuals Covered	115
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $3,718
Total amount of fees paid to insurance company	USD $1,031
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,859
Insurance broker organization code?	3
Amount paid for insurance broker fees	1031
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker name	ROBERT E. MUZIKOWSKI

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

655220

Policy instance

Insurance contract or identification number	655220
Number of Individuals Covered	119
Insurance policy start date	2008-10-01
Insurance policy end date	2009-01-31
Total amount of commissions paid to insurance broker	USD $4,014
Long Term Disability 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 $4,014
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

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

Policy contract number

TS05610978

Policy instance

Insurance contract or identification number	TS05610978
Number of Individuals Covered	412
Insurance policy start date	2009-01-01
Insurance policy end date	2009-12-31
Total amount of commissions paid to insurance broker	USD $12,066
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $135,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,752
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

HEALTH NET OF CT (National Association of Insurance Commissioners NAIC id number: 95968 )

Policy contract number

318562

Policy instance

Insurance contract or identification number	318562
Number of Individuals Covered	277
Insurance policy start date	2009-01-01
Insurance policy end date	2009-12-31
Total amount of commissions paid to insurance broker	USD $58,407
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,070,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,469
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS, INC.

HEALTH NET OF CT (National Association of Insurance Commissioners NAIC id number: 95968 )

Policy contract number

318562

Policy instance

Insurance contract or identification number	318562
Number of Individuals Covered	269
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $63,604
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,430,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,668
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS, INC.

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

656220

Policy instance

Insurance contract or identification number	656220
Number of Individuals Covered	150
Insurance policy start date	2007-10-01
Insurance policy end date	2008-09-30
Total amount of commissions paid to insurance broker	USD $18,795
Long Term Disability 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 $18,795
Insurance broker organization code?	3
Insurance broker name	ROBERT MUZIKOWSKI

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

Policy contract number

TS05610978

Policy instance

Insurance contract or identification number	TS05610978
Number of Individuals Covered	432
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $12,835
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $139,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,545
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	KABS AGENCY

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

656220

Policy instance

Insurance contract or identification number	656220
Number of Individuals Covered	150
Insurance policy start date	2006-10-01
Insurance policy end date	2007-09-30
Total amount of commissions paid to insurance broker	USD $18,008
Long Term Disability 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 $18,008
Insurance broker organization code?	3
Insurance broker name	ROBERT MUZIKOWSKI

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

Policy contract number

TS05610978

Policy instance

Insurance contract or identification number	TS05610978
Number of Individuals Covered	151
Insurance policy start date	2007-02-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $1,771
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $930
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	KABS AGENCY

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

Policy contract number

MH03,16,355,761

Policy instance

Insurance contract or identification number	MH03,16,355,761
Number of Individuals Covered	150
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $58,777
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,239,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MUZIKOWSKI

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Company Name:	ELLINGTON MANAGEMENT GROUP, LLC.
Employer identification number (EIN):	061441140
NAIC Classification:	523900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2015-09-02
Company Identification Number:	0802285742
Legal Registered Office Address:	15950 DALLAS PKWY STE 600 DALLAS United States of America (USA) 75248