401k Plan data: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN plan

TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	TEAMONE EMPLOYEE HEALTH BENEFIT PLAN
Plan identification number	501

TEAMONE EMPLOYEE HEALTH BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Supplemental unemployment Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

TEAM ONE CONTRACT SERVICES has sponsored the creation of one or more 401k plans.

Company Name: TEAM ONE CONTRACT SERVICES

Employer identification number (EIN): 200059104

NAIC Classification: 524290

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TEAMONE EMPLOYEE HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-03-01 PAGE SIPLON 2023-09-25
501 2021-03-01 PAGE SIPLON 2022-09-22
501 2020-03-01 PAGE SIPLON 2021-08-20
501 2020-03-01
501 2020-03-01 PAGE SIPLON 2021-08-20
501 2019-03-01 PAGE SIPLON 2020-12-08
501 2018-03-01
501 2017-03-01 PAGE SIPLON
501 2017-03-01
501 2016-03-01
501 2015-03-01
501 2014-03-01
501 2013-03-01

Plan Statistics for TEAMONE EMPLOYEE HEALTH BENEFIT PLAN

401k plan membership statisitcs for TEAMONE EMPLOYEE HEALTH BENEFIT PLAN

Measure Date Value
2022: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-03-01 595
Total number of active participants reported on line 7a of the Form 5500 2022-03-01 763
Number of retired or separated participants receiving benefits 2022-03-01 0
Number of other retired or separated participants entitled to future benefits 2022-03-01 0
Total of all active and inactive participants 2022-03-01 763
Number of employers contributing to the scheme 2022-03-01 0
2021: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-03-01 814
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 478
Number of retired or separated participants receiving benefits 2021-03-01 7
Number of other retired or separated participants entitled to future benefits 2021-03-01 110
Total of all active and inactive participants 2021-03-01 595
Number of employers contributing to the scheme 2021-03-01 0
2020: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-03-01 574
Total number of active participants reported on line 7a of the Form 5500 2020-03-01 814
Number of retired or separated participants receiving benefits 2020-03-01 0
Number of other retired or separated participants entitled to future benefits 2020-03-01 0
Total of all active and inactive participants 2020-03-01 814
2019: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-03-01 574
Total number of active participants reported on line 7a of the Form 5500 2019-03-01 844
Number of retired or separated participants receiving benefits 2019-03-01 4
Total of all active and inactive participants 2019-03-01 848
2018: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-03-01 607
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 804
Number of retired or separated participants receiving benefits 2018-03-01 3
Number of other retired or separated participants entitled to future benefits 2018-03-01 51
Total of all active and inactive participants 2018-03-01 858
2017: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-03-01 455
Total number of active participants reported on line 7a of the Form 5500 2017-03-01 574
Number of retired or separated participants receiving benefits 2017-03-01 3
Number of other retired or separated participants entitled to future benefits 2017-03-01 27
Total of all active and inactive participants 2017-03-01 604
2016: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 576
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 300
Number of retired or separated participants receiving benefits 2016-03-01 3
Total of all active and inactive participants 2016-03-01 303
2015: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 727
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 573
Number of retired or separated participants receiving benefits 2015-03-01 3
Total of all active and inactive participants 2015-03-01 576
2014: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-03-01 630
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 700
Number of retired or separated participants receiving benefits 2014-03-01 27
Total of all active and inactive participants 2014-03-01 727
2013: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-03-01 562
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 601
Number of retired or separated participants receiving benefits 2013-03-01 29
Total of all active and inactive participants 2013-03-01 630

Measure	Date	Value
2022: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-03-01	595
Total number of active participants reported on line 7a of the Form 5500	2022-03-01	763
Number of retired or separated participants receiving benefits	2022-03-01	0
Number of other retired or separated participants entitled to future benefits	2022-03-01	0
Total of all active and inactive participants	2022-03-01	763
Number of employers contributing to the scheme	2022-03-01	0
2021: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-03-01	814
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	478
Number of retired or separated participants receiving benefits	2021-03-01	7
Number of other retired or separated participants entitled to future benefits	2021-03-01	110
Total of all active and inactive participants	2021-03-01	595
Number of employers contributing to the scheme	2021-03-01	0
2020: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-03-01	574
Total number of active participants reported on line 7a of the Form 5500	2020-03-01	814
Number of retired or separated participants receiving benefits	2020-03-01	0
Number of other retired or separated participants entitled to future benefits	2020-03-01	0
Total of all active and inactive participants	2020-03-01	814
2019: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-03-01	574
Total number of active participants reported on line 7a of the Form 5500	2019-03-01	844
Number of retired or separated participants receiving benefits	2019-03-01	4
Total of all active and inactive participants	2019-03-01	848
2018: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	607
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	804
Number of retired or separated participants receiving benefits	2018-03-01	3
Number of other retired or separated participants entitled to future benefits	2018-03-01	51
Total of all active and inactive participants	2018-03-01	858
2017: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	455
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	574
Number of retired or separated participants receiving benefits	2017-03-01	3
Number of other retired or separated participants entitled to future benefits	2017-03-01	27
Total of all active and inactive participants	2017-03-01	604
2016: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	576
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	300
Number of retired or separated participants receiving benefits	2016-03-01	3
Total of all active and inactive participants	2016-03-01	303
2015: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	727
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	573
Number of retired or separated participants receiving benefits	2015-03-01	3
Total of all active and inactive participants	2015-03-01	576
2014: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	630
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	700
Number of retired or separated participants receiving benefits	2014-03-01	27
Total of all active and inactive participants	2014-03-01	727
2013: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	562
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	601
Number of retired or separated participants receiving benefits	2013-03-01	29
Total of all active and inactive participants	2013-03-01	630

Form 5500 Responses for TEAMONE EMPLOYEE HEALTH BENEFIT PLAN

2022: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2022 form 5500 responses
2022-03-01	Type of plan entity	Single employer plan
2022-03-01	Plan funding arrangement – Insurance	Yes
2022-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-03-01	Plan benefit arrangement – Insurance	Yes
2022-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2020 form 5500 responses
2020-03-01	Type of plan entity	Single employer plan
2020-03-01	Submission has been amended	No
2020-03-01	This submission is the final filing	No
2020-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-03-01	Plan is a collectively bargained plan	No
2020-03-01	Plan funding arrangement – Insurance	Yes
2020-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-03-01	Plan benefit arrangement – Insurance	Yes
2020-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Submission has been amended	No
2019-03-01	This submission is the final filing	No
2019-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-03-01	Plan is a collectively bargained plan	No
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Submission has been amended	No
2018-03-01	This submission is the final filing	No
2018-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-03-01	Plan is a collectively bargained plan	No
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Submission has been amended	No
2017-03-01	This submission is the final filing	No
2017-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-03-01	Plan is a collectively bargained plan	No
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: TEAMONE EMPLOYEE HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	First time form 5500 has been submitted	Yes
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	557
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $2,572
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,572
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	119
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $27,580
Total amount of fees paid to insurance company	USD $4,895
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $142,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,257
Amount paid for insurance broker fees	1475
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $156
Total amount of fees paid to insurance company	USD $0
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $1,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Number of Individuals Covered	59
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $1,370
Total amount of fees paid to insurance company	USD $90
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $787
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	763
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $57,729
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $317,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,729
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Number of Individuals Covered	68
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $4,956
Total amount of fees paid to insurance company	USD $5,292
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $20,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,649
Amount paid for insurance broker fees	1429
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $152
Total amount of fees paid to insurance company	USD $11
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	640
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,476
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,045
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	179
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $32,676
Total amount of fees paid to insurance company	USD $53,185
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $186,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,243
Amount paid for insurance broker fees	41297
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	773
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $58,127
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $317,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,739
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

WESTPOINT INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 39845 )

Policy contract number

200013400

Policy instance

Insurance contract or identification number	200013400
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $55,965
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $153
Total amount of fees paid to insurance company	USD $7
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	VOLUNTARY BENEFITS
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
Insurance broker organization code?	3
Number of Individuals Covered	2
Welfare Benefit Premiums Paid to Carrier	USD $1,638
Commission paid to Insurance Broker	USD $42
Amount paid for insurance broker fees	8
Additional information about fees paid to insurance broker	FEES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	814
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $0
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Welfare Benefit Premiums Paid to Carrier	USD $57,554
Commission paid to Insurance Broker	USD $2,878

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $52,113
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Number of Individuals Covered	815
Welfare Benefit Premiums Paid to Carrier	USD $466,666
Commission paid to Insurance Broker	USD $81,039

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Insurance policy start date	2018-03-31
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $25,760
Total amount of fees paid to insurance company	USD $4,018
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	VOLUNTARY BENEFITS
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
Insurance broker organization code?	3
Number of Individuals Covered	258
Welfare Benefit Premiums Paid to Carrier	USD $214,006
Commission paid to Insurance Broker	USD $14,076
Amount paid for insurance broker fees	4610
Additional information about fees paid to insurance broker	FEES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $5,378
Total amount of fees paid to insurance company	USD $681
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	VOLUNTARY BENEFITS
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
Insurance broker organization code?	3
Number of Individuals Covered	57
Welfare Benefit Premiums Paid to Carrier	USD $18,463
Commission paid to Insurance Broker	USD $939
Amount paid for insurance broker fees	301
Additional information about fees paid to insurance broker	FEES

LIBERTY INSURANCE UNDERWRITERS, INC. (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

TRU000102-03

Policy instance

Insurance contract or identification number	TRU000102-03
Number of Individuals Covered	477
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $499,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY INSURANCE UNDERWRITERS, INC. (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

TRU000207-01

Policy instance

Insurance contract or identification number	TRU000207-01
Number of Individuals Covered	458
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $381,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Number of Individuals Covered	50
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $9,034
Total amount of fees paid to insurance company	USD $927
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	VOLUNTARY 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 $27,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,972
Insurance broker organization code?	3
Amount paid for insurance broker fees	356
Additional information about fees paid to insurance broker	FEES PAID

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $165
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY 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 $2,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	0
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $66
Total amount of fees paid to insurance company	USD $74
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	VOLUNTARY 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 $278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42
Amount paid for insurance broker fees	74
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	250
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $47,747
Total amount of fees paid to insurance company	USD $6,464
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	VOLUNTARY 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 $227,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,119
Amount paid for insurance broker fees	3496
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	844
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $72,925
Total amount of fees paid to insurance company	USD $1,915
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $383,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,925
Amount paid for insurance broker fees	1915
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	404
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $2,759
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	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 $55,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,759
Insurance broker organization code?	3

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	860
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $68,428
Total amount of fees paid to insurance company	USD $1,793
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $336,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,428
Amount paid for insurance broker fees	1793
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $94
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, CRITICAL ILLNESS, CRITICAL CANCER
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52
Insurance broker organization code?	3

LIBERTY INSURANCE UNDERWRITERS, INC. (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

TRU000102-01

Policy instance

Insurance contract or identification number	TRU000102-01
Number of Individuals Covered	467
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $45,718
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $381,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,718
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Number of Individuals Covered	47
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $4,845
Total amount of fees paid to insurance company	USD $594
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	GROUP MEDICAL BRIDGE
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 $11,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,392
Insurance broker organization code?	3
Amount paid for insurance broker fees	69
Additional information about fees paid to insurance broker	FEES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	363
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $2,786
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	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 $55,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,786
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	248
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $26,102
Total amount of fees paid to insurance company	USD $3,911
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, UNIVERSAL LIFE, CANCER, CRITICAL ILLNESS, GROUP MEDICAL BRIDGE
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 $125,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,936
Insurance broker organization code?	3
Amount paid for insurance broker fees	1927
Additional information about fees paid to insurance broker	FEES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4540969

Policy instance

Insurance contract or identification number	E4540969
Number of Individuals Covered	50
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $5,378
Total amount of fees paid to insurance company	USD $681
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	VOLUNTARY 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 $20,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,173
Insurance broker organization code?	3
Amount paid for insurance broker fees	158
Additional information about fees paid to insurance broker	FEES
Insurance broker name	L H FINANCIAL SERVICES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $153
Total amount of fees paid to insurance company	USD $7
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	VOLUNTARY 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 $1,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	FEES
Insurance broker name	D'ARCIPRETE & ASSOCIATES INC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	234
Insurance policy start date	2017-03-31
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $25,760
Total amount of fees paid to insurance company	USD $4,018
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	VOLUNTARY 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 $147,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,514
Amount paid for insurance broker fees	1887
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	THOMAS A TURNER IV INSURANCE LLC

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	574
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $52,113
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $306,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,113
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT CO

WESTPOINT INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 39845 )

Policy contract number

200013400

Policy instance

Insurance contract or identification number	200013400
Number of Individuals Covered	362
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $55,965
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $373,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,965
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	307
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $2,289
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	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 $45,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,289
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY LLC

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	575
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $62,995
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $309,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,995
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	291
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $2,394
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,394
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $156
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $2,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48
Insurance broker organization code?	3
Insurance broker name	KLINGBEIL AND ASSOCIATES INC.

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	310
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $80,711
Total amount of fees paid to insurance company	USD $15,056
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $331,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80,711
Amount paid for insurance broker fees	15056
Additional information about fees paid to insurance broker	SERVICE
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHMENT

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

IHCRS-00197-15

Policy instance

Insurance contract or identification number	IHCRS-00197-15
Number of Individuals Covered	344
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-28
Total amount of commissions paid to insurance broker	USD $47,524
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $339,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,524
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	592
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $39,860
Total amount of fees paid to insurance company	USD $6,677
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $216,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,985
Insurance broker organization code?	3
Amount paid for insurance broker fees	6677
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	ALLIANT INS SVCS HOUSTON LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	341
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $3,085
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,085
Insurance broker organization code?	3
Insurance broker name	THE BENEFIT COMPANY

AMERICAN NATIONAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60739 )

Policy contract number

AN-1303004

Policy instance

Insurance contract or identification number	AN-1303004
Number of Individuals Covered	376
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $35,056
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	35056
Additional information about fees paid to insurance broker	CONSULTANT FEES
Insurance broker name	THE BENEFIT COMPANY

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $120
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $1,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36
Insurance broker organization code?	3
Insurance broker name	LESLIE WIERNIK

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	403
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $72,113
Total amount of fees paid to insurance company	USD $9,784
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $264,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,113
Amount paid for insurance broker fees	9784
Additional information about fees paid to insurance broker	SERVICE
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHMENT

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3328556

Policy instance

Insurance contract or identification number	E3328556
Number of Individuals Covered	460
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $59,098
Total amount of fees paid to insurance company	USD $8,441
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $266,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,098
Amount paid for insurance broker fees	8441
Additional information about fees paid to insurance broker	SERVICE
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHMENT

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3631306

Policy instance

Insurance contract or identification number	E3631306
Number of Individuals Covered	2
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $157
Total amount of fees paid to insurance company	USD $26
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $1,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79
Insurance broker organization code?	3
Amount paid for insurance broker fees	17
Additional information about fees paid to insurance broker	SERVICE
Insurance broker name	LESLIE WIERNIK

AMERICAN NATIONAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60739 )

Policy contract number

AN-1303004

Policy instance

Insurance contract or identification number	AN-1303004
Number of Individuals Covered	419
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

50890

Policy instance

Insurance contract or identification number	50890
Number of Individuals Covered	361
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $3,171
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,171
Insurance broker organization code?	3
Insurance broker name	GROUP RESOURCES, INC.

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

Policy contract number

678116G

Policy instance

Insurance contract or identification number	678116G
Number of Individuals Covered	577
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $57,009
Total amount of fees paid to insurance company	USD $6,068
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $281,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,009
Insurance broker organization code?	3
Amount paid for insurance broker fees	6068
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	ALLIANT INSURANCE SVCS INC

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Company Name:	TEAM ONE CONTRACT SERVICES
Employer identification number (EIN):	200059104
NAIC Classification:	524290

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-03-01	PAGE SIPLON	2023-09-25
501	2021-03-01	PAGE SIPLON	2022-09-22
501	2020-03-01	PAGE SIPLON	2021-08-20
501	2020-03-01
501	2020-03-01	PAGE SIPLON	2021-08-20
501	2019-03-01	PAGE SIPLON	2020-12-08
501	2018-03-01
501	2017-03-01	PAGE SIPLON
501	2017-03-01
501	2016-03-01
501	2015-03-01
501	2014-03-01
501	2013-03-01