401k Plan data: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN plan

AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN
Plan identification number	501

AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

AQUATECH INTERNATIONAL LLC has sponsored the creation of one or more 401k plans.

Company Name: AQUATECH INTERNATIONAL LLC

Employer identification number (EIN): 251401429

NAIC Classification: 562000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 JOANNE BLOOM JOANNE BLOOM 2018-09-26
501 2016-01-01 JOANNE BLOOM JOANNE BLOOM 2017-07-27
501 2015-01-01 JOANNE BLOOM JOANNE BLOOM 2016-07-26
501 2014-01-01 JOANNE BLOOM JOANNE BLOOM 2015-07-21
501 2013-01-01 JOANNE BLOOM JOANNE BLOOM 2014-10-02
501 2012-01-01 JOANNE BLOOM JOANNE BLOOM 2013-10-09
501 2011-01-01 JOANNE BLOOM JOANNE BLOOM 2012-11-06
501 2010-01-01 JOANNE BLOOM JOANNE BLOOM 2011-10-11
501 2009-01-01 JOANNE BLOOM JOANNE BLOOM 2010-10-12

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	JOANNE BLOOM	JOANNE BLOOM	2018-09-26
501	2016-01-01	JOANNE BLOOM	JOANNE BLOOM	2017-07-27
501	2015-01-01	JOANNE BLOOM	JOANNE BLOOM	2016-07-26
501	2014-01-01	JOANNE BLOOM	JOANNE BLOOM	2015-07-21
501	2013-01-01	JOANNE BLOOM	JOANNE BLOOM	2014-10-02
501	2012-01-01	JOANNE BLOOM	JOANNE BLOOM	2013-10-09
501	2011-01-01	JOANNE BLOOM	JOANNE BLOOM	2012-11-06
501	2010-01-01	JOANNE BLOOM	JOANNE BLOOM	2011-10-11
501	2009-01-01	JOANNE BLOOM	JOANNE BLOOM	2010-10-12

Plan Statistics for AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN

Measure Date Value
2022: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 195
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 195
2021: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 209
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 192
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 192
2020: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 172
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 165
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 165
2019: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 198
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 2019-01-01 198
2018: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 240
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 240
Number of retired or separated participants receiving benefits 2018-01-01 3
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 243
2017: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 217
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 226
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 2017-01-01 226
2016: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 199
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 2016-01-01 199
2015: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 232
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 200
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 2015-01-01 200
2014: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 239
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 232
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 2014-01-01 232
2013: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 239
Total of all active and inactive participants 2013-01-01 239
2012: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 212
Total of all active and inactive participants 2012-01-01 212
2011: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 193
Number of retired or separated participants receiving benefits 2011-01-01 3
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 196
2010: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 175
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 174
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 174
2009: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 175
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 175

Measure	Date	Value
2022: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	195
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	195
2021: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	209
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	192
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	192
2020: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	172
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	165
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	165
2019: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	198
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	198
2018: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	240
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	240
Number of retired or separated participants receiving benefits	2018-01-01	3
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	243
2017: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	217
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	226
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	226
2016: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	199
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	199
2015: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	232
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	200
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	200
2014: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	239
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	232
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	232
2013: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	239
Total of all active and inactive participants	2013-01-01	239
2012: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	212
Total of all active and inactive participants	2012-01-01	212
2011: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	193
Number of retired or separated participants receiving benefits	2011-01-01	3
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	196
2010: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	175
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	174
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	174
2009: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	175
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	175

Form 5500 Responses for AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN

2022: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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 – Insurance	Yes
2017: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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 – Insurance	Yes
2016: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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 – Insurance	Yes
2015: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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 – Insurance	Yes
2014: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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 – Insurance	Yes
2009: AQUATECH INTERNATIONAL CORPORATION FLEXIBLE BENEFITS PLAN 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

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	184
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,968
Total amount of fees paid to insurance company	USD $3,473
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,968
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	2874

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

Policy contract number

GVTL0962D

Policy instance

Insurance contract or identification number	GVTL0962D
Number of Individuals Covered	58
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,124
Total amount of fees paid to insurance company	USD $1,983
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $27,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,124
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	1641

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	184
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,175
Total amount of fees paid to insurance company	USD $1,727
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,175
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	1429

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	199
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,851
Total amount of fees paid to insurance company	USD $3,188
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $47,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,851
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	2638

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

512380000

Policy instance

Insurance contract or identification number	512380000
Number of Individuals Covered	310
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $486
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $486
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

271708

Policy instance

Insurance contract or identification number	271708
Number of Individuals Covered	324
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $43,963
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,463,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,963
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SN650

Policy instance

Insurance contract or identification number	SN650
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,420
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $18,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

512380001

Policy instance

Insurance contract or identification number	512380001
Number of Individuals Covered	14
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $26
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	180
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,151
Total amount of fees paid to insurance company	USD $2,065
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,151
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	1709

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

Policy contract number

271708

Policy instance

Insurance contract or identification number	271708
Number of Individuals Covered	346
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $58,317
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,344,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,317
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

512380000

Policy instance

Insurance contract or identification number	512380000
Number of Individuals Covered	327
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $506
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $506
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	189
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,734
Total amount of fees paid to insurance company	USD $3,658
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $44,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,734
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	3027

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SN650

Policy instance

Insurance contract or identification number	SN650
Number of Individuals Covered	25
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,342
Total amount of fees paid to insurance company	USD $41
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $19,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,715
Amount paid for insurance broker fees	33
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

512380001

Policy instance

Insurance contract or identification number	512380001
Number of Individuals Covered	14
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $40
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	180
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,915
Total amount of fees paid to insurance company	USD $4,043
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,915
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	3346

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

Policy contract number

GVTL0962D

Policy instance

Insurance contract or identification number	GVTL0962D
Number of Individuals Covered	93
Insurance policy start date	2019-02-01
Insurance policy end date	2020-02-01
Total amount of commissions paid to insurance broker	USD $5,194
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $37,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,194
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	202
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,434
Total amount of fees paid to insurance company	USD $382
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,434
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	382

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	202
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,155
Total amount of fees paid to insurance company	USD $748
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,155
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	748

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	206
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,019
Total amount of fees paid to insurance company	USD $692
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $50,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,019
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	692

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	374
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $612
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

906376

Policy instance

Insurance contract or identification number	906376
Number of Individuals Covered	409
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,325
Total amount of fees paid to insurance company	USD $52,757
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,189,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,325
Amount paid for insurance broker fees	52757
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SN650

Policy instance

Insurance contract or identification number	SN650
Number of Individuals Covered	27
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,334
Total amount of fees paid to insurance company	USD $277
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $52,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,925
Amount paid for insurance broker fees	220
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SN650

Policy instance

Insurance contract or identification number	SN650
Number of Individuals Covered	30
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,518
Total amount of fees paid to insurance company	USD $277
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $27,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,985
Amount paid for insurance broker fees	220
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

906376

Policy instance

Insurance contract or identification number	906376
Number of Individuals Covered	477
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,701
Total amount of fees paid to insurance company	USD $75,864
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,223,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,701
Amount paid for insurance broker fees	75864
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	249
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,145
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $55,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,145
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	238
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,259
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,259
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	238
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,544
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,544
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

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

Policy contract number

GVTL0962D

Policy instance

Insurance contract or identification number	GVTL0962D
Number of Individuals Covered	47
Insurance policy start date	2018-02-01
Insurance policy end date	2019-02-01
Total amount of commissions paid to insurance broker	USD $3,660
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $24,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,660
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	459
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $757
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $757
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SN650

Policy instance

Insurance contract or identification number	SN650
Number of Individuals Covered	39
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,600
Total amount of fees paid to insurance company	USD $47
Other welfare benefits provided	VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $31,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,119
Amount paid for insurance broker fees	40
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	EUGENE MAMMOME

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

906376

Policy instance

Insurance contract or identification number	906376
Number of Individuals Covered	461
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $85,300
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,356,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	85300
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	510
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $793
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $793
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK, INC

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

920269

Policy instance

Insurance contract or identification number	920269
Number of Individuals Covered	213
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,711
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $164,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,711
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	249
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,673
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $43,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,673
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	249
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,363
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,363
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	249
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,621
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,621
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	231
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,453
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $39,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,453
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	490
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $831
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $831
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK, INC

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

Policy contract number

00495896

Policy instance

Insurance contract or identification number	00495896
Number of Individuals Covered	211
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,040
Total amount of fees paid to insurance company	USD $7,926
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,491
Amount paid for insurance broker fees	7926
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841800

Policy instance

Insurance contract or identification number	016841800
Number of Individuals Covered	287
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,193
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,000,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,193
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841903

Policy instance

Insurance contract or identification number	016841903
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $18
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841904

Policy instance

Insurance contract or identification number	016841904
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $-323
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-323
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	231
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,737
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,737
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841801

Policy instance

Insurance contract or identification number	016841801
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $655
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $655
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	231
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,200
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,200
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841304

Policy instance

Insurance contract or identification number	016841304
Number of Individuals Covered	157
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,091
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $638,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,091
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841904

Policy instance

Insurance contract or identification number	016841904
Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $989
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $989
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	524
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $550
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $550
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK, INC

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	249
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,582
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,582
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	249
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,859
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,859
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	253
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,477
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $39,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,477
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841801

Policy instance

Insurance contract or identification number	016841801
Number of Individuals Covered	8
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $460
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $460
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

00495896

Policy instance

Insurance contract or identification number	00495896
Number of Individuals Covered	222
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,338
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,168
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker name	ARMS INSURANCE GROUP INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841800

Policy instance

Insurance contract or identification number	016841800
Number of Individuals Covered	293
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $38,594
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,115,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,594
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841903

Policy instance

Insurance contract or identification number	016841903
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $37
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841304

Policy instance

Insurance contract or identification number	016841304
Number of Individuals Covered	164
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $15,257
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $623,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,257
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	229
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,784
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,784
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	253
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,460
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $39,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,460
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	231
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,548
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,548
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK IN

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

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	708
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $767
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $767
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK, INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841304

Policy instance

Insurance contract or identification number	016841304
Number of Individuals Covered	126
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,719
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $512,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,719
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWPRK INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841902

Policy instance

Insurance contract or identification number	016841902
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $39
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841303

Policy instance

Insurance contract or identification number	016841303
Number of Individuals Covered	329
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $26,871
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,168,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,871
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

TM05722489

Policy instance

Insurance contract or identification number	TM05722489
Number of Individuals Covered	475
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,052
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,567
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker name	NFP INS SERVICES INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

016841903

Policy instance

Insurance contract or identification number	016841903
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $171
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $171
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

TM05722489

Policy instance

Insurance contract or identification number	TM05722489
Number of Individuals Covered	482
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,760
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,381
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker name	NFP INS SERVICES INC

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846900

Policy instance

Insurance contract or identification number	016846900
Number of Individuals Covered	2
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $391
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $391
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841301

Policy instance

Insurance contract or identification number	016841301
Number of Individuals Covered	106
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,233
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $369,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,233
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	243
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,456
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,456
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK IN

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	241
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,651
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,651
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	247
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,412
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $38,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,412
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841900

Policy instance

Insurance contract or identification number	016841900
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $14
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORD

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841901

Policy instance

Insurance contract or identification number	016841901
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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 name	BENEFITS NETWORK

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846300

Policy instance

Insurance contract or identification number	016846300
Number of Individuals Covered	85
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,154
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $263,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,154
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846301

Policy instance

Insurance contract or identification number	016846301
Number of Individuals Covered	25
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,300
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,300
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841300

Policy instance

Insurance contract or identification number	016841300
Number of Individuals Covered	251
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $19,989
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $799,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,989
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	704
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $770
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $770
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK, INC

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841900

Policy instance

Insurance contract or identification number	016841900
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $93
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	234
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,138
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D D
Welfare Benefit Premiums Paid to Carrier	USD $32,749
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

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	666
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $662
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841302

Policy instance

Insurance contract or identification number	016841302
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

016841001

Policy instance

Insurance contract or identification number	016841001
Number of Individuals Covered	5
Insurance policy start date	2011-04-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846301

Policy instance

Insurance contract or identification number	016846301
Number of Individuals Covered	21
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $722
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846300

Policy instance

Insurance contract or identification number	016846300
Number of Individuals Covered	101
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,159
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $499,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016846901

Policy instance

Insurance contract or identification number	016846901
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $23
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841901

Policy instance

Insurance contract or identification number	016841901
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $86
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	226
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,428
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	227
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,271
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

TM05722489

Policy instance

Insurance contract or identification number	TM05722489
Number of Individuals Covered	442
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,069
Total amount of fees paid to insurance company	USD $206
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $134,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841301

Policy instance

Insurance contract or identification number	016841301
Number of Individuals Covered	83
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,679
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $457,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

016841300

Policy instance

Insurance contract or identification number	016841300
Number of Individuals Covered	230
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $24,278
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $236,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

TM05722489

Policy instance

Insurance contract or identification number	TM05722489
Number of Individuals Covered	377
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,844
Total amount of fees paid to insurance company	USD $2,122
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,675
Amount paid for insurance broker fees	2122
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NFP SECURITIES, INC

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

2176560000

Policy instance

Insurance contract or identification number	2176560000
Number of Individuals Covered	306
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,023
Total amount of fees paid to insurance company	USD $4,056
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $440,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,023
Insurance broker organization code?	3
Amount paid for insurance broker fees	4056
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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

Policy contract number

GLTD0962D

Policy instance

Insurance contract or identification number	GLTD0962D
Number of Individuals Covered	200
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,994
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,994
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK IN

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

Policy contract number

GLUG0962D

Policy instance

Insurance contract or identification number	GLUG0962D
Number of Individuals Covered	205
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,828
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D D
Welfare Benefit Premiums Paid to Carrier	USD $28,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,828
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

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

Policy contract number

51238

Policy instance

Insurance contract or identification number	51238
Number of Individuals Covered	395
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $595
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $595
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK, INC

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

Policy contract number

GUG0962D

Policy instance

Insurance contract or identification number	GUG0962D
Number of Individuals Covered	200
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,570
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,570
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

2176560000

Policy instance

Insurance contract or identification number	2176560000
Number of Individuals Covered	75
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,618
Total amount of fees paid to insurance company	USD $1,056
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $304,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,618
Insurance broker organization code?	3
Amount paid for insurance broker fees	1056
Additional information about fees paid to insurance broker	RETENTION
Insurance broker name	BENEFITS NETWORK INC

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Company Name:	AQUATECH INTERNATIONAL LLC
Employer identification number (EIN):	251401429
NAIC Classification:	562000