401k Plan data: CROWN ROLL LEAF INC plan

CROWN ROLL LEAF INC 401k Plan overview

Plan Name	CROWN ROLL LEAF INC
Plan identification number	501

CROWN ROLL LEAF INC Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CROWN ROLL LEAF, INC. has sponsored the creation of one or more 401k plans.

Company Name: CROWN ROLL LEAF, INC.

Employer identification number (EIN): 221980418

NAIC Classification: 323100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CROWN ROLL LEAF INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01
501 2018-01-01
501 2017-01-01 VINCENT DIFIORE VINCENT DIFIORE 2018-10-12
501 2016-01-01 VINCENT DIFIORE VINCENT DIFIORE 2017-10-11
501 2015-01-01 VINCENT DIFIORE VINCENT DIFIORE 2016-10-11
501 2014-01-01 VINCENT DIFIORE VINCENT DIFIORE 2015-10-09
501 2013-01-01 VINCENT DIFIORE VINCENT DIFIORE 2014-10-10
501 2012-01-01 VINCENT DIFIORE VINCENT DIFIORE 2013-10-14
501 2011-01-01 VINCENT DIFIORE VINCENT DIFIORE 2012-10-05
501 2010-01-01 VINCENT DIFIORE VINCENT DIFIORE 2011-10-14
501 2009-01-01 VINCENT DIFIORE

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2019-01-01
501	2018-01-01
501	2017-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2018-10-12
501	2016-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2017-10-11
501	2015-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2016-10-11
501	2014-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2015-10-09
501	2013-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2014-10-10
501	2012-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2013-10-14
501	2011-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2012-10-05
501	2010-01-01	VINCENT DIFIORE	VINCENT DIFIORE	2011-10-14
501	2009-01-01	VINCENT DIFIORE

Plan Statistics for CROWN ROLL LEAF INC

401k plan membership statisitcs for CROWN ROLL LEAF INC

Measure Date Value
2019: CROWN ROLL LEAF INC 2019 401k membership
Total participants, beginning-of-year 2019-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
2018: CROWN ROLL LEAF INC 2018 401k membership
Total participants, beginning-of-year 2018-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 0
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 0
2017: CROWN ROLL LEAF INC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
2016: CROWN ROLL LEAF INC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: CROWN ROLL LEAF INC 2015 401k membership
Total participants, beginning-of-year 2015-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: CROWN ROLL LEAF INC 2014 401k membership
Total participants, beginning-of-year 2014-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: CROWN ROLL LEAF INC 2013 401k membership
Total participants, beginning-of-year 2013-01-01 89
Total of all active and inactive participants 2013-01-01 0
2012: CROWN ROLL LEAF INC 2012 401k membership
Total participants, beginning-of-year 2012-01-01 85
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 89
Total of all active and inactive participants 2012-01-01 89
2011: CROWN ROLL LEAF INC 2011 401k membership
Total participants, beginning-of-year 2011-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 85
Total of all active and inactive participants 2011-01-01 85
2010: CROWN ROLL LEAF INC 2010 401k membership
Total participants, beginning-of-year 2010-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 101
Total of all active and inactive participants 2010-01-01 101
2009: CROWN ROLL LEAF INC 2009 401k membership
Total participants, beginning-of-year 2009-01-01 114
Total of all active and inactive participants 2009-01-01 0
Total participants 2009-01-01 0

Measure	Date	Value
2019: CROWN ROLL LEAF INC 2019 401k membership
Total participants, beginning-of-year	2019-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
2018: CROWN ROLL LEAF INC 2018 401k membership
Total participants, beginning-of-year	2018-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	0
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	0
2017: CROWN ROLL LEAF INC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
2016: CROWN ROLL LEAF INC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: CROWN ROLL LEAF INC 2015 401k membership
Total participants, beginning-of-year	2015-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: CROWN ROLL LEAF INC 2014 401k membership
Total participants, beginning-of-year	2014-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: CROWN ROLL LEAF INC 2013 401k membership
Total participants, beginning-of-year	2013-01-01	89
Total of all active and inactive participants	2013-01-01	0
2012: CROWN ROLL LEAF INC 2012 401k membership
Total participants, beginning-of-year	2012-01-01	85
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	89
Total of all active and inactive participants	2012-01-01	89
2011: CROWN ROLL LEAF INC 2011 401k membership
Total participants, beginning-of-year	2011-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	85
Total of all active and inactive participants	2011-01-01	85
2010: CROWN ROLL LEAF INC 2010 401k membership
Total participants, beginning-of-year	2010-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	101
Total of all active and inactive participants	2010-01-01	101
2009: CROWN ROLL LEAF INC 2009 401k membership
Total participants, beginning-of-year	2009-01-01	114
Total of all active and inactive participants	2009-01-01	0
Total participants	2009-01-01	0

Financial Data on CROWN ROLL LEAF INC

Measure	Date	Value
2019 : CROWN ROLL LEAF INC 2019 401k financial data
Total plan liabilities at beginning of year	2019-12-31	$1
Total income from all sources	2019-12-31	$0
Total plan assets at end of year	2019-12-31	$0
Total plan assets at beginning of year	2019-12-31	$1
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$0
2018 : CROWN ROLL LEAF INC 2018 401k financial data
Total plan liabilities at end of year	2018-12-31	$1
Total income from all sources	2018-12-31	$0
Total plan assets at end of year	2018-12-31	$1
Total plan assets at beginning of year	2018-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$0
2017 : CROWN ROLL LEAF INC 2017 401k financial data
Total income from all sources	2017-12-31	$0
Total plan assets at end of year	2017-12-31	$0
Total plan assets at beginning of year	2017-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$0
2016 : CROWN ROLL LEAF INC 2016 401k financial data
Total income from all sources	2016-12-31	$0
Total plan assets at end of year	2016-12-31	$0
Total plan assets at beginning of year	2016-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$0
2015 : CROWN ROLL LEAF INC 2015 401k financial data
Total income from all sources	2015-12-31	$0
Total plan assets at end of year	2015-12-31	$0
Total plan assets at beginning of year	2015-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$0
2014 : CROWN ROLL LEAF INC 2014 401k financial data
Total income from all sources	2014-12-31	$0
Total plan assets at end of year	2014-12-31	$0
Total plan assets at beginning of year	2014-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$0
2013 : CROWN ROLL LEAF INC 2013 401k financial data
Total income from all sources	2013-12-31	$0
Total plan assets at end of year	2013-12-31	$0
Total plan assets at beginning of year	2013-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$0
2012 : CROWN ROLL LEAF INC 2012 401k financial data
Total income from all sources	2012-12-31	$0
Total plan assets at end of year	2012-12-31	$0
Total plan assets at beginning of year	2012-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$0
2011 : CROWN ROLL LEAF INC 2011 401k financial data
Total income from all sources	2011-12-31	$0
Total plan assets at end of year	2011-12-31	$0
Total plan assets at beginning of year	2011-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0
2010 : CROWN ROLL LEAF INC 2010 401k financial data
Total plan assets at end of year	2010-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$0

Form 5500 Responses for CROWN ROLL LEAF INC

2019: CROWN ROLL LEAF INC 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	This submission is the final filing	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: CROWN ROLL LEAF INC 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: CROWN ROLL LEAF INC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CROWN ROLL LEAF INC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: CROWN ROLL LEAF INC 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: CROWN ROLL LEAF INC 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: CROWN ROLL LEAF INC 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: CROWN ROLL LEAF INC 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: CROWN ROLL LEAF INC 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: CROWN ROLL LEAF INC 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: CROWN ROLL LEAF INC 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

572990

Policy instance

Insurance contract or identification number	572990
Number of Individuals Covered	71
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,391
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,432

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	45
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $30,725
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $774,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,725

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	45
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,650
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,650
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

572990

Policy instance

Insurance contract or identification number	572990
Number of Individuals Covered	124
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,979
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,724

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	44
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $47,521
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $727,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,755
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	45
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,600
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,410
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	42
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $44,308
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $705,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,762
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICE NATIONAL

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

572990

Policy instance

Insurance contract or identification number	572990
Number of Individuals Covered	129
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,675
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,516
Insurance broker name	WELLS FARGO INSURANCE SVCS

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	50
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,605
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $193
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	56
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	62
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,888
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,888
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	74
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,352
Total amount of fees paid to insurance company	USD $1,630
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,352
Amount paid for insurance broker fees	1630
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	48
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $33,320
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $789,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,320
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO UNSURANCE

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	56
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $44,983
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $824,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,983
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO UNSURANCE

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	74
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,041
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,041
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICE

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	56
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,919
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $138,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,919
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	84
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,531
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,531
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	74
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,041
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,041
Insurance broker name	WELLS FARGO INSURANCE SERVICE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	84
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,531
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,531
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

13896975

Policy instance

Insurance contract or identification number	13896975
Number of Individuals Covered	56
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $44,983
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $824,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,983
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	89
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,490
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,490
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

085663

Policy instance

Insurance contract or identification number	085663
Number of Individuals Covered	76
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,661
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,661
Insurance broker organization code?	3
Insurance broker name	WACHOVIA INSURANCE SERVICES

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	62
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $45,826
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $960,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,826
Insurance broker name	WACHOVIA INSURANCE SERVICES INC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

085663

Policy instance

Insurance contract or identification number	085663
Number of Individuals Covered	79
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,323
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	96
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,741
Total amount of fees paid to insurance company	USD $2,191
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $32,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	85
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $59,161
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,182,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

85663

Policy instance

Insurance contract or identification number	85663
Number of Individuals Covered	101
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $63,987
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,279,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F005357

Policy instance

Insurance contract or identification number	F005357
Number of Individuals Covered	98
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,839
Total amount of fees paid to insurance company	USD $2,289
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $34,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

085663

Policy instance

Insurance contract or identification number	085663
Number of Individuals Covered	101
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,568
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CROWN ROLL LEAF, INC.
Employer identification number (EIN):	221980418
NAIC Classification:	323100