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SESAME WORKSHOP GROUP BENEFITS PLAN 401k Plan overview

Plan NameSESAME WORKSHOP GROUP BENEFITS PLAN
Plan identification number 501

SESAME WORKSHOP GROUP BENEFITS PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    SESAME WORKSHOP has sponsored the creation of one or more 401k plans.

    Company Name:SESAME WORKSHOP
    Employer identification number (EIN):132655731
    NAIC Classification:512100
    NAIC Description: Motion Picture and Video Industries

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan SESAME WORKSHOP GROUP BENEFITS PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5012019-01-01JAMES MOTTEE2020-07-29
    5012018-01-01JAMES MOTTEE2019-07-26
    5012017-01-01
    5012016-01-01JAMES MOTTEE
    5012015-01-01JAMES MOTTEE
    5012014-01-01DARYL MINTZ
    5012013-01-01DARYL MINTZ
    5012012-01-01DARYL MINTZ
    5012011-01-01DARYL MINTZ
    5012010-01-01DARYL MINTZ
    5012009-01-01DARYL MINTZ

    Plan Statistics for SESAME WORKSHOP GROUP BENEFITS PLAN

    401k plan membership statisitcs for SESAME WORKSHOP GROUP BENEFITS PLAN

    Measure Date Value
    2019
    Total participants, beginning-of-year2019-01-01296
    Total number of active participants reported on line 7a of the Form 55002019-01-01307
    Number of retired or separated participants receiving benefits2019-01-017
    Number of other retired or separated participants entitled to future benefits2019-01-010
    Total of all active and inactive participants2019-01-01314
    2018
    Total participants, beginning-of-year2018-01-01295
    Total number of active participants reported on line 7a of the Form 55002018-01-01291
    Number of retired or separated participants receiving benefits2018-01-0110
    Number of other retired or separated participants entitled to future benefits2018-01-014
    Total of all active and inactive participants2018-01-01305
    Number of employers contributing to the scheme2018-01-010
    2017
    Total participants, beginning-of-year2017-01-01279
    Total number of active participants reported on line 7a of the Form 55002017-01-01285
    Number of retired or separated participants receiving benefits2017-01-014
    Number of other retired or separated participants entitled to future benefits2017-01-016
    Total of all active and inactive participants2017-01-01295
    2016
    Total participants, beginning-of-year2016-01-01289
    Total number of active participants reported on line 7a of the Form 55002016-01-01242
    Number of retired or separated participants receiving benefits2016-01-0112
    Number of other retired or separated participants entitled to future benefits2016-01-010
    Total of all active and inactive participants2016-01-01254
    2015
    Total participants, beginning-of-year2015-01-01268
    Total number of active participants reported on line 7a of the Form 55002015-01-01257
    Number of retired or separated participants receiving benefits2015-01-0124
    Number of other retired or separated participants entitled to future benefits2015-01-010
    Total of all active and inactive participants2015-01-01281
    2014
    Total participants, beginning-of-year2014-01-01264
    Total number of active participants reported on line 7a of the Form 55002014-01-01228
    Number of retired or separated participants receiving benefits2014-01-0113
    Number of other retired or separated participants entitled to future benefits2014-01-010
    Total of all active and inactive participants2014-01-01241
    2013
    Total participants, beginning-of-year2013-01-01285
    Total number of active participants reported on line 7a of the Form 55002013-01-01264
    Number of retired or separated participants receiving benefits2013-01-010
    Number of other retired or separated participants entitled to future benefits2013-01-010
    Total of all active and inactive participants2013-01-01264
    2012
    Total participants, beginning-of-year2012-01-01332
    Total number of active participants reported on line 7a of the Form 55002012-01-01329
    Number of retired or separated participants receiving benefits2012-01-0112
    Number of other retired or separated participants entitled to future benefits2012-01-010
    Total of all active and inactive participants2012-01-01341
    2011
    Total participants, beginning-of-year2011-01-01312
    Total number of active participants reported on line 7a of the Form 55002011-01-01337
    Number of retired or separated participants receiving benefits2011-01-0111
    Number of other retired or separated participants entitled to future benefits2011-01-010
    Total of all active and inactive participants2011-01-01348
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2011-01-010
    2010
    Total participants, beginning-of-year2010-01-01357
    Total number of active participants reported on line 7a of the Form 55002010-01-01289
    Number of retired or separated participants receiving benefits2010-01-0122
    Number of other retired or separated participants entitled to future benefits2010-01-010
    Total of all active and inactive participants2010-01-01311
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2010-01-011
    Total participants2010-01-01312
    2009
    Total participants, beginning-of-year2009-01-01358
    Total number of active participants reported on line 7a of the Form 55002009-01-01307
    Number of retired or separated participants receiving benefits2009-01-0150
    Number of other retired or separated participants entitled to future benefits2009-01-010
    Total of all active and inactive participants2009-01-01357
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010

    Form 5500 Responses

    2019
    2019-01-01Type of plan entitySingle employer plan
    2019-01-01Submission has been amendedNo
    2019-01-01This submission is the final filingNo
    2019-01-01This return/report is a short plan year return/report (less than 12 months)No
    2019-01-01Plan is a collectively bargained planNo
    2019-01-01Plan funding arrangement – InsuranceYes
    2019-01-01Plan funding arrangement – General assets of the sponsorYes
    2019-01-01Plan benefit arrangement – InsuranceYes
    2019-01-01Plan benefit arrangement – General assets of the sponsorYes
    2018
    2018-01-01Type of plan entitySingle employer plan
    2018-01-01Plan funding arrangement – InsuranceYes
    2018-01-01Plan funding arrangement – General assets of the sponsorYes
    2018-01-01Plan benefit arrangement – InsuranceYes
    2018-01-01Plan benefit arrangement – General assets of the sponsorYes
    2017
    2017-01-01Type of plan entitySingle employer plan
    2017-01-01Plan funding arrangement – InsuranceYes
    2017-01-01Plan funding arrangement – General assets of the sponsorYes
    2017-01-01Plan benefit arrangement – InsuranceYes
    2017-01-01Plan benefit arrangement – General assets of the sponsorYes
    2016
    2016-01-01Type of plan entitySingle employer plan
    2016-01-01Submission has been amendedNo
    2016-01-01This submission is the final filingNo
    2016-01-01This return/report is a short plan year return/report (less than 12 months)No
    2016-01-01Plan is a collectively bargained planNo
    2016-01-01Plan funding arrangement – InsuranceYes
    2016-01-01Plan funding arrangement – General assets of the sponsorYes
    2016-01-01Plan benefit arrangement – InsuranceYes
    2016-01-01Plan benefit arrangement – General assets of the sponsorYes
    2015
    2015-01-01Type of plan entitySingle employer plan
    2015-01-01Submission has been amendedNo
    2015-01-01This submission is the final filingNo
    2015-01-01This return/report is a short plan year return/report (less than 12 months)No
    2015-01-01Plan is a collectively bargained planNo
    2015-01-01Plan funding arrangement – InsuranceYes
    2015-01-01Plan benefit arrangement – InsuranceYes
    2014
    2014-01-01Type of plan entitySingle employer plan
    2014-01-01Submission has been amendedNo
    2014-01-01This submission is the final filingNo
    2014-01-01This return/report is a short plan year return/report (less than 12 months)No
    2014-01-01Plan is a collectively bargained planNo
    2014-01-01Plan funding arrangement – InsuranceYes
    2014-01-01Plan benefit arrangement – InsuranceYes
    2013
    2013-01-01Type of plan entitySingle employer plan
    2013-01-01Submission has been amendedNo
    2013-01-01This submission is the final filingNo
    2013-01-01This return/report is a short plan year return/report (less than 12 months)No
    2013-01-01Plan is a collectively bargained planNo
    2013-01-01Plan funding arrangement – InsuranceYes
    2013-01-01Plan benefit arrangement – InsuranceYes
    2012
    2012-01-01Type of plan entitySingle employer plan
    2012-01-01Submission has been amendedNo
    2012-01-01This submission is the final filingNo
    2012-01-01This return/report is a short plan year return/report (less than 12 months)No
    2012-01-01Plan is a collectively bargained planNo
    2012-01-01Plan funding arrangement – InsuranceYes
    2012-01-01Plan funding arrangement – General assets of the sponsorYes
    2012-01-01Plan benefit arrangement – InsuranceYes
    2012-01-01Plan benefit arrangement – General assets of the sponsorYes
    2011
    2011-01-01Type of plan entitySingle employer plan
    2011-01-01Submission has been amendedNo
    2011-01-01This submission is the final filingNo
    2011-01-01This return/report is a short plan year return/report (less than 12 months)No
    2011-01-01Plan is a collectively bargained planNo
    2011-01-01Plan funding arrangement – InsuranceYes
    2011-01-01Plan benefit arrangement – InsuranceYes
    2010
    2010-01-01Type of plan entitySingle employer plan
    2010-01-01Submission has been amendedNo
    2010-01-01This submission is the final filingNo
    2010-01-01This return/report is a short plan year return/report (less than 12 months)No
    2010-01-01Plan is a collectively bargained planNo
    2010-01-01Plan funding arrangement – InsuranceYes
    2010-01-01Plan benefit arrangement – InsuranceYes
    2009
    2009-01-01Type of plan entitySingle employer plan
    2009-01-01Submission has been amendedNo
    2009-01-01This submission is the final filingNo
    2009-01-01This return/report is a short plan year return/report (less than 12 months)No
    2009-01-01Plan is a collectively bargained planNo
    2009-01-01Plan funding arrangement – InsuranceYes
    2009-01-01Plan benefit arrangement – InsuranceYes

    Insurance Providers Used on plan

    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 6
    Insurance contract or identification number12269582
    Number of Individuals Covered205
    Insurance policy start date2018-07-01
    Insurance policy end date2019-06-30
    Total amount of commissions paid to insurance brokerUSD $1,326
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $29,859
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,326
    Insurance broker organization code?3
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 5
    Insurance contract or identification number984
    Number of Individuals Covered307
    Insurance policy start date2018-06-12
    Insurance policy end date2019-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedKIDNAPPING & RANSOM
    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 CarrierUSD $0
    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 number07393A
    Policy instance 4
    Insurance contract or identification number07393A
    Number of Individuals Covered1
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $837
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $8,370
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $837
    Insurance broker organization code?3
    CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
    Policy contract numberFLY960453
    Policy instance 3
    Insurance contract or identification numberFLY960453
    Number of Individuals Covered307
    Insurance policy start date2018-07-01
    Insurance policy end date2019-06-30
    Total amount of commissions paid to insurance brokerUSD $6,202
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $127,511
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $6,202
    Insurance broker organization code?3
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number2499342
    Policy instance 2
    Insurance contract or identification number2499342
    Number of Individuals Covered512
    Insurance policy start date2018-07-01
    Insurance policy end date2019-06-30
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $669,869
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number6477-57-77
    Policy instance 1
    Insurance contract or identification number6477-57-77
    Number of Individuals Covered307
    Insurance policy start date2018-05-30
    Insurance policy end date2019-05-29
    Total amount of commissions paid to insurance brokerUSD $8,304
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedBUSINESS TRAVEL 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 CarrierUSD $23,724
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $4,745
    Insurance broker organization code?3
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number3199292
    Policy instance 1
    Insurance contract or identification number3199292
    Number of Individuals Covered473
    Insurance policy start date2017-07-01
    Insurance policy end date2018-06-30
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $576,377
    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: 47029 )
    Policy contract number12269582
    Policy instance 2
    Insurance contract or identification number12269582
    Number of Individuals Covered194
    Insurance policy start date2017-07-01
    Insurance policy end date2018-06-30
    Total amount of commissions paid to insurance brokerUSD $1,259
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $27,428
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 3
    Insurance contract or identification number984
    Number of Individuals Covered291
    Insurance policy start date2017-06-12
    Insurance policy end date2018-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Other welfare benefits providedKIDNAPPING & RANSOM
    Welfare Benefit Premiums Paid to CarrierUSD $7,087
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number6477-57-77
    Policy instance 5
    Insurance contract or identification number6477-57-77
    Number of Individuals Covered291
    Insurance policy start date2017-05-30
    Insurance policy end date2018-05-29
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
    Welfare Benefit Premiums Paid to CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number07393A
    Policy instance 4
    Insurance contract or identification number07393A
    Number of Individuals Covered1
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $837
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $8,370
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
    Policy contract numberFLY960453
    Policy instance 6
    Insurance contract or identification numberFLY960453
    Number of Individuals Covered291
    Insurance policy start date2017-07-01
    Insurance policy end date2018-06-30
    Total amount of commissions paid to insurance brokerUSD $7,091
    Total amount of fees paid to insurance companyUSD $2,898
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    Welfare Benefit Premiums Paid to CarrierUSD $147,844
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 2
    Insurance contract or identification number984
    Number of Individuals Covered285
    Insurance policy start date2016-06-12
    Insurance policy end date2017-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Other welfare benefits providedKIDNAPPING & RANSOM
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
    Policy contract numberFLY960453
    Policy instance 4
    Insurance contract or identification numberFLY960453
    Number of Individuals Covered285
    Insurance policy start date2016-07-01
    Insurance policy end date2017-06-30
    Total amount of commissions paid to insurance brokerUSD $5,402
    Total amount of fees paid to insurance companyUSD $8,153
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    Welfare Benefit Premiums Paid to CarrierUSD $124,491
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    Commission paid to Insurance BrokerUSD $5,402
    Amount paid for insurance broker fees8153
    Additional information about fees paid to insurance brokerOVERRIDE
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number3199292
    Policy instance 5
    Insurance contract or identification number3199292
    Number of Individuals Covered426
    Insurance policy start date2016-07-01
    Insurance policy end date2017-06-30
    Total amount of commissions paid to insurance brokerUSD $621
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Welfare Benefit Premiums Paid to CarrierUSD $478,268
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    Commission paid to Insurance BrokerUSD $621
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number6477-5777
    Policy instance 3
    Insurance contract or identification number6477-5777
    Number of Individuals Covered285
    Insurance policy start date2016-05-30
    Insurance policy end date2017-05-29
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
    Welfare Benefit Premiums Paid to CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 1
    Insurance contract or identification number12269582
    Number of Individuals Covered170
    Insurance policy start date2016-07-01
    Insurance policy end date2017-06-30
    Total amount of commissions paid to insurance brokerUSD $1,166
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $24,097
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,166
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number3199292
    Policy instance 1
    Insurance contract or identification number3199292
    Number of Individuals Covered437
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $432,292
    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 number873924G
    Policy instance 3
    Insurance contract or identification number873924G
    Number of Individuals Covered264
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $14,379
    Total amount of fees paid to insurance companyUSD $924
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $135,639
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $14,379
    Amount paid for insurance broker fees924
    Additional information about fees paid to insurance brokerBONUS
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number64775777
    Policy instance 4
    Insurance contract or identification number64775777
    Number of Individuals Covered257
    Insurance policy start date2014-05-30
    Insurance policy end date2015-05-29
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract numberNA645
    Policy instance 5
    Insurance contract or identification numberNA645
    Number of Individuals Covered13
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $665
    Total amount of fees paid to insurance companyUSD $22
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOLUNTARY BENEFITS
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $5,511
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $170
    Amount paid for insurance broker fees9
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    ESI (National Association of Insurance Commissioners NAIC id number: 62419 )
    Policy contract number3446
    Policy instance 6
    Insurance contract or identification number3446
    Number of Individuals Covered287
    Insurance policy start date2014-03-01
    Insurance policy end date2015-02-28
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM.
    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 CarrierUSD $7,080
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 7
    Insurance contract or identification number984
    Number of Individuals Covered257
    Insurance policy start date2014-06-12
    Insurance policy end date2015-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedKIDNAPPING AND RANSOM
    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 CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 2
    Insurance contract or identification number12269582
    Number of Individuals Covered151
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $1,076
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $19,158
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,076
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    ESI (National Association of Insurance Commissioners NAIC id number: 62419 )
    Policy contract number3446
    Policy instance 7
    Insurance contract or identification number3446
    Number of Individuals Covered287
    Insurance policy start date2013-03-01
    Insurance policy end date2014-02-28
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM.
    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 CarrierUSD $7,080
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 6
    Insurance contract or identification number984
    Number of Individuals Covered228
    Insurance policy start date2013-06-12
    Insurance policy end date2014-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedKIDNAPPING AND RANSOM
    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?Yes
    AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract numberNA645
    Policy instance 5
    Insurance contract or identification numberNA645
    Number of Individuals Covered15
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $750
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOLUNTARY BENEFITS
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $5,504
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $188
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number6477-57-77
    Policy instance 4
    Insurance contract or identification number6477-57-77
    Number of Individuals Covered228
    Insurance policy start date2013-05-30
    Insurance policy end date2014-05-29
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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?Yes
    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 3
    Insurance contract or identification number12269582
    Number of Individuals Covered145
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $1,076
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $19,159
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,076
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
    Policy contract number873924G
    Policy instance 2
    Insurance contract or identification number873924G
    Number of Individuals Covered271
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $13,183
    Total amount of fees paid to insurance companyUSD $3,553
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $108,763
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $13,183
    Amount paid for insurance broker fees3553
    Additional information about fees paid to insurance brokerBONUS
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number3199292
    Policy instance 1
    Insurance contract or identification number3199292
    Number of Individuals Covered481
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $473,311
    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 number3199292
    Policy instance 1
    Insurance contract or identification number3199292
    Number of Individuals Covered510
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $489,418
    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: 47029 )
    Policy contract number12269582
    Policy instance 3
    Insurance contract or identification number12269582
    Number of Individuals Covered151
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $1,094
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $19,665
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,094
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number5749
    Policy instance 4
    Insurance contract or identification number5749
    Number of Individuals Covered279
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $160,205
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number6477-57-77
    Policy instance 5
    Insurance contract or identification number6477-57-77
    Number of Individuals Covered264
    Insurance policy start date2012-05-30
    Insurance policy end date2013-05-29
    Total amount of commissions paid to insurance brokerUSD $7,456
    Total amount of fees paid to insurance companyUSD $435
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $24,855
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
    Commission paid to Insurance BrokerUSD $3,728
    Amount paid for insurance broker fees435
    Additional information about fees paid to insurance brokerGUARANTEED SUPPLEMENTAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameINSURANCE SERVICES GROUP, INC.
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract numberNA645
    Policy instance 6
    Insurance contract or identification numberNA645
    Number of Individuals Covered15
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $802
    Total amount of fees paid to insurance companyUSD $13
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOLUNTARY BENEFITS
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $7,292
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $741
    Amount paid for insurance broker fees13
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number984
    Policy instance 7
    Insurance contract or identification number984
    Number of Individuals Covered337
    Insurance policy start date2012-06-12
    Insurance policy end date2013-06-11
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedKIDNAPPING AND RANSOM
    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
    METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
    Policy contract number25782
    Policy instance 2
    Insurance contract or identification number25782
    Number of Individuals Covered546
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $19
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $360,551
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Amount paid for insurance broker fees19
    Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 1
    Insurance contract or identification number12269582
    Number of Individuals Covered163
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,113
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $20,221
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,113
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 2
    Insurance contract or identification number05749
    Number of Individuals Covered314
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOL LIFE, VOL DEP LIFE SPOUSE/FAM, VOL DEP LIFE CHILD ,AD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $210,941
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    U.S. SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 29599 )
    Policy contract number
    Policy instance 8
    Number of Individuals Covered337
    Insurance policy start date2011-06-12
    Insurance policy end date2012-06-11
    Total amount of commissions paid to insurance brokerUSD $1,013
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedKIDNAPPING & RANSOM
    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 CarrierUSD $6,750
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,013
    Insurance broker organization code?3
    Insurance broker nameARC EXCESS & SURPLUS, LLC
    HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
    Policy contract number2P37471A9AA
    Policy instance 3
    Insurance contract or identification number2P37471A9AA
    Number of Individuals Covered478
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,044
    Total amount of fees paid to insurance companyUSD $108
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedWD-STAT
    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 CarrierUSD $20,887
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,044
    Amount paid for insurance broker fees108
    Additional information about fees paid to insurance brokerBONUS
    Insurance broker nameREUBEN WARNER ASSOCIATES
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract numberNA645
    Policy instance 4
    Insurance contract or identification numberNA645
    Number of Individuals Covered15
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,034
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAFLAC POLICIES
    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 CarrierUSD $9,693
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $324
    Insurance broker organization code?3
    Insurance broker nameBLAINE L. KELLER
    METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
    Policy contract number0025782
    Policy instance 6
    Insurance contract or identification number0025782
    Number of Individuals Covered574
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $25
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $371,344
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Amount paid for insurance broker fees25
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number3199292
    Policy instance 5
    Insurance contract or identification number3199292
    Number of Individuals Covered553
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $416,339
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number64775777
    Policy instance 7
    Insurance contract or identification number64775777
    Number of Individuals Covered329
    Insurance policy start date2011-06-02
    Insurance policy end date2012-05-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
    Policy contract number0025782
    Policy instance 4
    Insurance contract or identification number0025782
    Number of Individuals Covered585
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $14
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $371,915
    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: 47029 )
    Policy contract number12269582
    Policy instance 3
    Insurance contract or identification number12269582
    Number of Individuals Covered161
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $1,040
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $18,542
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 1
    Insurance contract or identification number05749
    Number of Individuals Covered49
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $37,351
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
    Policy contract number2P37471A9AA
    Policy instance 9
    Insurance contract or identification number2P37471A9AA
    Number of Individuals Covered478
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $1,134
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $22,681
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 8
    Insurance contract or identification number05749
    Number of Individuals Covered324
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $12,767
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 7
    Insurance contract or identification number05749
    Number of Individuals Covered324
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $60,374
    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 number3199292
    Policy instance 2
    Insurance contract or identification number3199292
    Number of Individuals Covered548
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $305,835
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number000064775777
    Policy instance 5
    Insurance contract or identification number000064775777
    Insurance policy start date2010-05-31
    Insurance policy end date2011-05-30
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $0
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 6
    Insurance contract or identification number05749
    Number of Individuals Covered324
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $101,368
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 1
    Insurance contract or identification number05749
    Number of Individuals Covered51
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedGROUP UNIVERSAL LIFE INSURANCE
    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 CarrierUSD $29,146
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 2
    Insurance contract or identification number05749
    Number of Individuals Covered313
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $57,930
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
    Policy contract number2P37471A9AA
    Policy instance 4
    Insurance contract or identification number2P37471A9AA
    Number of Individuals Covered289
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $1,099
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $20,564
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Amount paid for insurance broker fees1099
    Additional information about fees paid to insurance brokerSALES & CONTINGENT COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameREUBEN WARNER ASSSOCIATES
    METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
    Policy contract number0025782
    Policy instance 9
    Insurance contract or identification number0025782
    Number of Individuals Covered574
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $12
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $373,579
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Amount paid for insurance broker fees12
    Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP INC
    VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
    Policy contract number12269582
    Policy instance 8
    Insurance contract or identification number12269582
    Number of Individuals Covered144
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $1,068
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $18,962
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,068
    Insurance broker organization code?3
    Insurance broker nameCORPORATE SYNERGIES GROUP INC
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 7
    Insurance contract or identification number05749
    Number of Individuals Covered313
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $12,219
    PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
    Policy contract number05749
    Policy instance 6
    Insurance contract or identification number05749
    Number of Individuals Covered313
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $97,035
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
    Policy contract number000064775777
    Policy instance 5
    Insurance contract or identification number000064775777
    Number of Individuals Covered289
    Insurance policy start date2009-05-31
    Insurance policy end date2010-05-30
    Total amount of commissions paid to insurance brokerUSD $7,094
    Total amount of fees paid to insurance companyUSD $939
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $23,645
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,547
    Amount paid for insurance broker fees939
    Additional information about fees paid to insurance brokerVOLUME AND RETENTION BONUS
    Insurance broker organization code?3
    Insurance broker nameINSURANCE SERVICES GROUP INC
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number3199292
    Policy instance 3
    Insurance contract or identification number3199292
    Number of Individuals Covered300
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $3,577,467
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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