401k Plan data: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS plan

FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 401k Plan overview

Plan Name	FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS
Plan identification number	501

FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS Benefits

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

401k Sponsoring company profile

FS-ELLIOTT CO., LLC has sponsored the creation of one or more 401k plans.

Company Name: FS-ELLIOTT CO., LLC

Employer identification number (EIN): 113703424

NAIC Classification: 333610

Additional information about FS-ELLIOTT CO., LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2003-11-05

Company Identification Number: 0800268906

Legal Registered Office Address: 5710 MELLON RD

EXPORT
United States of America (USA)
15632

More information about FS-ELLIOTT CO., LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01 KEITH MACURDY KEITH MACURDY 2016-09-20
501 2014-01-01 KEITH MACURDY KEITH MACURDY 2015-07-16
501 2013-01-01 KEITH MACURDY KEITH MACURDY 2014-09-09
501 2012-01-01 KEITH MACURDY KEITH MACURDY 2013-05-20
501 2011-01-01 KEITH MACURDY KEITH MACURDY 2012-05-02
501 2009-01-01 KEITH MACURDY

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2015-01-01	KEITH MACURDY	KEITH MACURDY	2016-09-20
501	2014-01-01	KEITH MACURDY	KEITH MACURDY	2015-07-16
501	2013-01-01	KEITH MACURDY	KEITH MACURDY	2014-09-09
501	2012-01-01	KEITH MACURDY	KEITH MACURDY	2013-05-20
501	2011-01-01	KEITH MACURDY	KEITH MACURDY	2012-05-02
501	2009-01-01	KEITH MACURDY

Plan Statistics for FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS

401k plan membership statisitcs for FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS

Measure Date Value
2015: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 280
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 280
Total of all active and inactive participants 2014-01-01 280
2013: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 270
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 278
Total of all active and inactive participants 2013-01-01 278
2012: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2012 401k membership
Total participants, beginning-of-year 2012-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 270
Total of all active and inactive participants 2012-01-01 270
2011: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2011 401k membership
Total participants, beginning-of-year 2011-01-01 215
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 257
Total of all active and inactive participants 2011-01-01 257
2009: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2009 401k membership
Total participants, beginning-of-year 2009-01-01 210
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 182
Total of all active and inactive participants 2009-01-01 182

Measure	Date	Value
2015: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	280
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	280
Total of all active and inactive participants	2014-01-01	280
2013: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	270
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	278
Total of all active and inactive participants	2013-01-01	278
2012: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	270
Total of all active and inactive participants	2012-01-01	270
2011: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	215
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	257
Total of all active and inactive participants	2011-01-01	257
2009: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	210
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	182
Total of all active and inactive participants	2009-01-01	182

Form 5500 Responses for FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS

2015: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	This submission is the final filing	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 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: FS-ELLIOTT CO., LLC HEALTH PLAN MEDICAL, DRUG, VISION, DENTAL BENEFITS 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01118148

Policy instance

Insurance contract or identification number	01118148
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $113,145
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,579,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $113,145
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

03804A

Policy instance

Insurance contract or identification number	03804A
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,893
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	EVACUATION
Welfare Benefit Premiums Paid to Carrier	USD $135,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,893
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,533
Total amount of fees paid to insurance company	USD $0
Vision 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 $1,533
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000ARNA

Policy instance

Insurance contract or identification number	G000ARNA
Number of Individuals Covered	283
Insurance policy start date	2015-01-01
Insurance policy end date	2015-11-01
Total amount of commissions paid to insurance broker	USD $4,843
Total amount of fees paid to insurance company	USD $1,087
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,843
Amount paid for insurance broker fees	1087
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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

Policy contract number

03804A

Policy instance

Insurance contract or identification number	03804A
Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,388
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	EVACUATION
Welfare Benefit Premiums Paid to Carrier	USD $117,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,388
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01118148

Policy instance

Insurance contract or identification number	01118148
Number of Individuals Covered	666
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $125,898
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,157,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125,898
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000ARNA

Policy instance

Insurance contract or identification number	G000ARNA
Number of Individuals Covered	281
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,083
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $194,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,083
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	285
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,799
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision 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 $1,799
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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

Policy contract number

03804A

Policy instance

Insurance contract or identification number	03804A
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,491
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	EVACUATION
Welfare Benefit Premiums Paid to Carrier	USD $93,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,491
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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

Policy contract number

TM05572615

Policy instance

Insurance contract or identification number	TM05572615
Number of Individuals Covered	861
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,962
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $210,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,962
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01458073

Policy instance

Insurance contract or identification number	01458073
Number of Individuals Covered	733
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $119,777
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,102,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119,777
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	284
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,826
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision 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 $1,826
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01458073

Policy instance

Insurance contract or identification number	01458073
Number of Individuals Covered	640
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $131,955
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,725,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $131,955
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

03804A

Policy instance

Insurance contract or identification number	03804A
Number of Individuals Covered	2
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,563
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,563
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	279
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,769
Total amount of fees paid to insurance company	USD $8,848
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,769
Amount paid for insurance broker fees	8848
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICE FEES & RISKS AND OTHER CONTINGENCIES
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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

Policy contract number

TM05572615

Policy instance

Insurance contract or identification number	TM05572615
Number of Individuals Covered	858
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,758
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,758
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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

Policy contract number

TM05572615

Policy instance

Insurance contract or identification number	TM05572615
Number of Individuals Covered	593
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,277
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

1148611

Policy instance

Insurance contract or identification number	1148611
Number of Individuals Covered	588
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $93,920
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,310,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	262
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,268
Total amount of fees paid to insurance company	USD $6,342
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2594

Policy instance

Insurance contract or identification number	2594
Number of Individuals Covered	216
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $901
Total amount of fees paid to insurance company	USD $4,504
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $901
Amount paid for insurance broker fees	4504
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICE FEES & RISKS AND OTHER CONTINGENCIES
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

1148611

Policy instance

Insurance contract or identification number	1148611
Number of Individuals Covered	485
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $83,915
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,068,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,915
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

TM05572615

Policy instance

Insurance contract or identification number	TM05572615
Number of Individuals Covered	504
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,836
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,836
Insurance broker organization code?	3
Insurance broker name	CHRIS G VOLK

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Company Name:	FS-ELLIOTT CO., LLC
Employer identification number (EIN):	113703424
NAIC Classification:	333610

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2003-11-05
Company Identification Number:	0800268906
Legal Registered Office Address:	5710 MELLON RD EXPORT United States of America (USA) 15632