401k Plan data: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN plan

M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN
Plan identification number	503

M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

M J ENGINEERING AND LAND SURVEYING has sponsored the creation of one or more 401k plans.

Company Name: M J ENGINEERING AND LAND SURVEYING

Employer identification number (EIN): 141610087

NAIC Classification: 541330
NAIC Description: Engineering Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-06-01 DEBORAH L. WALDRUFF 2024-02-23
503 2021-06-01 DEBORAH WALDRUFF 2023-02-08
503 2020-06-01
503 2019-06-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
503	2022-06-01	DEBORAH L. WALDRUFF	2024-02-23
503	2021-06-01	DEBORAH WALDRUFF	2023-02-08
503	2020-06-01
503	2019-06-01

Plan Statistics for M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN

401k plan membership statisitcs for M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN

Measure Date Value
2022: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 121
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 134
Number of retired or separated participants receiving benefits 2022-06-01 2
Number of other retired or separated participants entitled to future benefits 2022-06-01 4
Total of all active and inactive participants 2022-06-01 140
2021: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 117
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 121
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 121
2020: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 109
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 117
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 117
2019: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 101
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 109
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 109

Measure	Date	Value
2022: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	121
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	134
Number of retired or separated participants receiving benefits	2022-06-01	2
Number of other retired or separated participants entitled to future benefits	2022-06-01	4
Total of all active and inactive participants	2022-06-01	140
2021: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	117
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	121
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	121
2020: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	109
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	117
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	117
2019: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	101
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	109
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	109

Form 5500 Responses for M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN

2022: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Submission has been amended	No
2020-06-01	This submission is the final filing	No
2020-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-06-01	Plan is a collectively bargained plan	No
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: M J ENGINEERING AND LAND SURVEYING WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	First time form 5500 has been submitted	Yes
2019-06-01	Submission has been amended	No
2019-06-01	This submission is the final filing	No
2019-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-06-01	Plan is a collectively bargained plan	No
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNITED CONCIERGE MEDICINE (National Association of Insurance Commissioners NAIC id number: 62139 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	217
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMEDICINE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

281127

Policy instance

Insurance contract or identification number	281127
Number of Individuals Covered	122
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $44,954
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $222,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,954
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMG0B2BH

Policy instance

Insurance contract or identification number	GMG0B2BH
Number of Individuals Covered	134
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1,797
Total amount of fees paid to insurance company	USD $720
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,797
Amount paid for insurance broker fees	508
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMTD0B2BH

Policy instance

Insurance contract or identification number	GMTD0B2BH
Number of Individuals Covered	134
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,423
Total amount of fees paid to insurance company	USD $657
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,423
Amount paid for insurance broker fees	464
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

MP0B2BH

Policy instance

Insurance contract or identification number	MP0B2BH
Number of Individuals Covered	134
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $265
Total amount of fees paid to insurance company	USD $106
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $265
Amount paid for insurance broker fees	75
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

GLCL0B2BH

Policy instance

Insurance contract or identification number	GLCL0B2BH
Number of Individuals Covered	134
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1,042
Total amount of fees paid to insurance company	USD $282
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $924
Amount paid for insurance broker fees	282
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

GCEL0B2BH

Policy instance

Insurance contract or identification number	GCEL0B2BH
Number of Individuals Covered	45
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,343
Total amount of fees paid to insurance company	USD $939
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,343
Amount paid for insurance broker fees	663
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

00539615

Policy instance

Insurance contract or identification number	00539615
Number of Individuals Covered	109
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $4,701
Total amount of fees paid to insurance company	USD $5,344
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $127,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,701
Amount paid for insurance broker fees	5344
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

0228072

Policy instance

Insurance contract or identification number	0228072
Number of Individuals Covered	39
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $799
Total amount of fees paid to insurance company	USD $247
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $742
Amount paid for insurance broker fees	247
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

0228073

Policy instance

Insurance contract or identification number	0228073
Number of Individuals Covered	112
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $787
Total amount of fees paid to insurance company	USD $184
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $736
Amount paid for insurance broker fees	184
Additional information about fees paid to insurance broker	COMMISSION AND FEES
Insurance broker organization code?	3

LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 54111 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	17
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1,226
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,226
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	41
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,937
Total amount of fees paid to insurance company	USD $1,364
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,937
Amount paid for insurance broker fees	1129
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

00539615

Policy instance

Insurance contract or identification number	00539615
Number of Individuals Covered	101
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $4,595
Total amount of fees paid to insurance company	USD $4,795
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $118,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,595
Amount paid for insurance broker fees	4795
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

0228072

Policy instance

Insurance contract or identification number	0228072
Number of Individuals Covered	23
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $970
Total amount of fees paid to insurance company	USD $572
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $924
Amount paid for insurance broker fees	572
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

0228073

Policy instance

Insurance contract or identification number	0228073
Number of Individuals Covered	93
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,369
Total amount of fees paid to insurance company	USD $631
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,313
Amount paid for insurance broker fees	631
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 54111 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	10
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $953
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $953
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

UNITED CONCIERGE MEDICINE (National Association of Insurance Commissioners NAIC id number: 62139 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	87
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-30
Total amount of commissions paid to insurance broker	USD $504
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMEDICINE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $504
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	121
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $967
Total amount of fees paid to insurance company	USD $668
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $967
Amount paid for insurance broker fees	553
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	121
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $239
Total amount of fees paid to insurance company	USD $167
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $239
Amount paid for insurance broker fees	138
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	121
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $2,063
Total amount of fees paid to insurance company	USD $958
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,063
Amount paid for insurance broker fees	793
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	121
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,559
Total amount of fees paid to insurance company	USD $1,089
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,559
Amount paid for insurance broker fees	901
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00969235

Policy instance

Insurance contract or identification number	00969235
Number of Individuals Covered	196
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $35,603
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,603
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00969235

Policy instance

Insurance contract or identification number	00969235
Number of Individuals Covered	187
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $35,632
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,632
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	117
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,428
Total amount of fees paid to insurance company	USD $164
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,428
Insurance broker organization code?	3
Amount paid for insurance broker fees	164
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	117
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,880
Total amount of fees paid to insurance company	USD $153
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,880
Insurance broker organization code?	3
Amount paid for insurance broker fees	153
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	117
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $217
Total amount of fees paid to insurance company	USD $26
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $217
Insurance broker organization code?	3
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	117
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $868
Total amount of fees paid to insurance company	USD $116
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $868
Insurance broker organization code?	3
Amount paid for insurance broker fees	116
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	42
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,830
Total amount of fees paid to insurance company	USD $219
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,830
Insurance broker organization code?	3
Amount paid for insurance broker fees	219
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES

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

Policy contract number

00539615

Policy instance

Insurance contract or identification number	00539615
Number of Individuals Covered	96
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $4,249
Total amount of fees paid to insurance company	USD $5,314
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $103,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,249
Amount paid for insurance broker fees	5314
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

0228072

Policy instance

Insurance contract or identification number	0228072
Number of Individuals Covered	28
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $412
Total amount of fees paid to insurance company	USD $231
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $404
Amount paid for insurance broker fees	231
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

0228073

Policy instance

Insurance contract or identification number	0228073
Number of Individuals Covered	41
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $800
Total amount of fees paid to insurance company	USD $533
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL WORKSITE BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $789
Amount paid for insurance broker fees	336
Additional information about fees paid to insurance broker	ADMINISTRATIVE & OTHER FEES
Insurance broker organization code?	3

LEGAL CLUB OF AMERICA (National Association of Insurance Commissioners NAIC id number: 54111 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	5
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $283
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $243
Insurance broker organization code?	3

UNITED CONCIERGE MEDICINE (National Association of Insurance Commissioners NAIC id number: 62139 )

Policy contract number

MJE

Policy instance

Insurance contract or identification number	MJE
Number of Individuals Covered	80
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $517
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMEDICINE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $517
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	109
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,769
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,769
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	109
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,143
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,143
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000B2BH

Policy instance

Insurance contract or identification number	G000B2BH
Number of Individuals Covered	109
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,019
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,019
Insurance broker organization code?	3

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Company Name:	M J ENGINEERING AND LAND SURVEYING
Employer identification number (EIN):	141610087
NAIC Classification:	541330
NAIC Description:	Engineering Services