UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN
Plan identification number	501

UNITED FASHIONS OF TEXAS, LLC WELFARE 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

401k Sponsoring company profile

UNITED FASHIONS OF TEXAS LLC has sponsored the creation of one or more 401k plans.

Company Name:	UNITED FASHIONS OF TEXAS LLC
Employer identification number (EIN):	260433691
NAIC Classification:	448120
NAIC Description:	Women's Clothing Stores

Additional information about UNITED FASHIONS OF TEXAS LLC

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2007-06-25
Company Identification Number:	0800834535
Legal Registered Office Address:	4629 MACRO C/O ACCOUNTS PAYABLE SAN ANTONIO 78218

More information about UNITED FASHIONS OF TEXAS LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-08-01
501	2021-08-01
501	2020-08-01
501	2019-08-01
501	2018-08-01
501	2017-08-01
501	2016-08-01	JOEL JACOBSEN
501	2015-08-01	JOEL JACOBSEN
501	2014-08-01	JOEL JACOBSEN
501	2013-08-01	DUANE HUESERS
501	2012-08-01	DUANE HUESERS
501	2011-08-01	STEPHEN LANE
501	2009-08-01	STEPHEN LANE
501	2008-08-01	STEPHEN LANE
501	2007-08-01	STEPHEN LANE

Plan Statistics for UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN

Measure	Date	Value
2022: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-08-01	186
Total number of active participants reported on line 7a of the Form 5500	2022-08-01	186
Number of retired or separated participants receiving benefits	2022-08-01	0
Number of other retired or separated participants entitled to future benefits	2022-08-01	0
Total of all active and inactive participants	2022-08-01	186
2021: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-08-01	186
Total number of active participants reported on line 7a of the Form 5500	2021-08-01	186
Number of retired or separated participants receiving benefits	2021-08-01	0
Number of other retired or separated participants entitled to future benefits	2021-08-01	0
Total of all active and inactive participants	2021-08-01	186
2020: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-08-01	170
Total number of active participants reported on line 7a of the Form 5500	2020-08-01	186
Number of retired or separated participants receiving benefits	2020-08-01	0
Number of other retired or separated participants entitled to future benefits	2020-08-01	0
Total of all active and inactive participants	2020-08-01	186
2019: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-08-01	171
Total number of active participants reported on line 7a of the Form 5500	2019-08-01	170
Number of retired or separated participants receiving benefits	2019-08-01	0
Number of other retired or separated participants entitled to future benefits	2019-08-01	0
Total of all active and inactive participants	2019-08-01	170
2018: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-08-01	160
Total number of active participants reported on line 7a of the Form 5500	2018-08-01	171
Number of retired or separated participants receiving benefits	2018-08-01	0
Number of other retired or separated participants entitled to future benefits	2018-08-01	0
Total of all active and inactive participants	2018-08-01	171
2017: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-08-01	191
Total number of active participants reported on line 7a of the Form 5500	2017-08-01	160
Number of retired or separated participants receiving benefits	2017-08-01	0
Number of other retired or separated participants entitled to future benefits	2017-08-01	0
Total of all active and inactive participants	2017-08-01	160
2016: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	162
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	191
Number of retired or separated participants receiving benefits	2016-08-01	0
Number of other retired or separated participants entitled to future benefits	2016-08-01	0
Total of all active and inactive participants	2016-08-01	191
2015: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	164
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	162
Number of retired or separated participants receiving benefits	2015-08-01	0
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	162
2014: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	167
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	164
Number of retired or separated participants receiving benefits	2014-08-01	0
Number of other retired or separated participants entitled to future benefits	2014-08-01	0
Total of all active and inactive participants	2014-08-01	164
2013: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-08-01	176
Total number of active participants reported on line 7a of the Form 5500	2013-08-01	167
Number of retired or separated participants receiving benefits	2013-08-01	0
Number of other retired or separated participants entitled to future benefits	2013-08-01	0
Total of all active and inactive participants	2013-08-01	167
2012: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-08-01	180
Total number of active participants reported on line 7a of the Form 5500	2012-08-01	176
Number of retired or separated participants receiving benefits	2012-08-01	0
Number of other retired or separated participants entitled to future benefits	2012-08-01	0
Total of all active and inactive participants	2012-08-01	176
2011: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-08-01	182
Total number of active participants reported on line 7a of the Form 5500	2011-08-01	179
Number of retired or separated participants receiving benefits	2011-08-01	1
Number of other retired or separated participants entitled to future benefits	2011-08-01	0
Total of all active and inactive participants	2011-08-01	180
2009: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-08-01	127
Total number of active participants reported on line 7a of the Form 5500	2009-08-01	131
Number of retired or separated participants receiving benefits	2009-08-01	3
Number of other retired or separated participants entitled to future benefits	2009-08-01	0
Total of all active and inactive participants	2009-08-01	134
2008: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year	2008-08-01	134
Total number of active participants reported on line 7a of the Form 5500	2008-08-01	127
Number of retired or separated participants receiving benefits	2008-08-01	0
Number of other retired or separated participants entitled to future benefits	2008-08-01	0
Total of all active and inactive participants	2008-08-01	127
2007: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year	2007-08-01	130
Total number of active participants reported on line 7a of the Form 5500	2007-08-01	134
Number of retired or separated participants receiving benefits	2007-08-01	0
Number of other retired or separated participants entitled to future benefits	2007-08-01	0
Total of all active and inactive participants	2007-08-01	134

Form 5500 Responses for UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN

2022: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-08-01	Type of plan entity	Single employer plan
2022-08-01	Submission has been amended	No
2022-08-01	This submission is the final filing	No
2022-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-08-01	Plan is a collectively bargained plan	No
2022-08-01	Plan funding arrangement – Insurance	Yes
2022-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-08-01	Plan benefit arrangement – Insurance	Yes
2022-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-08-01	Type of plan entity	Single employer plan
2021-08-01	Submission has been amended	No
2021-08-01	This submission is the final filing	No
2021-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-08-01	Plan is a collectively bargained plan	No
2021-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-08-01	Plan benefit arrangement – Insurance	Yes
2021-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-08-01	Type of plan entity	Single employer plan
2020-08-01	Submission has been amended	No
2020-08-01	This submission is the final filing	No
2020-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-08-01	Plan is a collectively bargained plan	No
2020-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-08-01	Plan benefit arrangement – Insurance	Yes
2020-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-08-01	Type of plan entity	Single employer plan
2019-08-01	Submission has been amended	No
2019-08-01	This submission is the final filing	No
2019-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-08-01	Plan is a collectively bargained plan	No
2019-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-08-01	Plan benefit arrangement – Insurance	Yes
2019-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Submission has been amended	No
2018-08-01	This submission is the final filing	No
2018-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-08-01	Plan is a collectively bargained plan	No
2018-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-08-01	Type of plan entity	Single employer plan
2017-08-01	Submission has been amended	No
2017-08-01	This submission is the final filing	No
2017-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-08-01	Plan is a collectively bargained plan	No
2017-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-08-01	Plan benefit arrangement – Insurance	Yes
2017-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	Submission has been amended	No
2016-08-01	This submission is the final filing	No
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-08-01	Plan is a collectively bargained plan	No
2016-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2014: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Submission has been amended	No
2014-08-01	This submission is the final filing	No
2014-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-08-01	Plan is a collectively bargained plan	No
2014-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2013: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-08-01	Type of plan entity	Single employer plan
2013-08-01	Submission has been amended	No
2013-08-01	This submission is the final filing	No
2013-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-08-01	Plan is a collectively bargained plan	No
2013-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-08-01	Plan benefit arrangement – Insurance	Yes
2012: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-08-01	Type of plan entity	Single employer plan
2012-08-01	Submission has been amended	No
2012-08-01	This submission is the final filing	No
2012-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-08-01	Plan is a collectively bargained plan	No
2012-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-08-01	Plan benefit arrangement – Insurance	Yes
2011: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-08-01	Type of plan entity	Single employer plan
2011-08-01	Submission has been amended	No
2011-08-01	This submission is the final filing	No
2011-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-08-01	Plan is a collectively bargained plan	No
2011-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-08-01	Plan benefit arrangement – Insurance	Yes
2009: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-08-01	Type of plan entity	Single employer plan
2009-08-01	Submission has been amended	No
2009-08-01	This submission is the final filing	No
2009-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-08-01	Plan is a collectively bargained plan	No
2009-08-01	Plan funding arrangement – Insurance	Yes
2009-08-01	Plan benefit arrangement – Insurance	Yes
2008: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-08-01	Type of plan entity	Single employer plan
2008-08-01	Submission has been amended	No
2008-08-01	This submission is the final filing	No
2008-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-08-01	Plan is a collectively bargained plan	No
2008-08-01	Plan funding arrangement – Insurance	Yes
2008-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2008-08-01	Plan benefit arrangement – Insurance	Yes
2008-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2007: UNITED FASHIONS OF TEXAS, LLC WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-08-01	Type of plan entity	Single employer plan
2007-08-01	Submission has been amended	No
2007-08-01	This submission is the final filing	No
2007-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-08-01	Plan is a collectively bargained plan	No
2007-08-01	Plan funding arrangement – Insurance	Yes
2007-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-08-01	Plan benefit arrangement – Insurance	Yes
2007-08-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDU
Policy instance	2
Insurance contract or identification number GVTL0AGDU Number of Individuals Covered 95 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $2,864 Total amount of fees paid to insurance company USD $2,065 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,864 Amount paid for insurance broker fees 2065 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDU
Policy instance	1
Insurance contract or identification number GLUG0AGDU Number of Individuals Covered 46 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $1,397 Total amount of fees paid to insurance company USD $987 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,397 Amount paid for insurance broker fees 987 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDU
Policy instance	3
Insurance contract or identification number GUPR0AGDU Number of Individuals Covered 24 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $625 Total amount of fees paid to insurance company USD $486 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,252 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $625 Amount paid for insurance broker fees 486 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	417002415050
Policy instance	4
Insurance contract or identification number 417002415050 Number of Individuals Covered 186 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $324,752 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	GLLV0AGDU
Policy instance	5
Insurance contract or identification number GLLV0AGDU Number of Individuals Covered 129 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $2,056 Total amount of fees paid to insurance company USD $1,510 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,556 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,056 Amount paid for insurance broker fees 1510 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUDB0AGDU
Policy instance	6
Insurance contract or identification number GUDB0AGDU Number of Individuals Covered 141 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $1,890 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $51,127 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1890 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	417003415050
Policy instance	7
Insurance contract or identification number 417003415050 Number of Individuals Covered 186 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $1,042 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,442 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,042 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AGDU
Policy instance	8
Insurance contract or identification number GUC0AGDU Number of Individuals Covered 59 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $2,416 Total amount of fees paid to insurance company USD $1,679 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,159 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,416 Amount paid for insurance broker fees 1679 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDU
Policy instance	9
Insurance contract or identification number GLTD0AGDU Number of Individuals Covered 45 Insurance policy start date 2021-09-01 Insurance policy end date 2022-08-31 Total amount of commissions paid to insurance broker USD $761 Total amount of fees paid to insurance company USD $544 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,610 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $761 Amount paid for insurance broker fees 544 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUDB0AGDU
Policy instance	3
Insurance contract or identification number GUDB0AGDU Number of Individuals Covered 139 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $484 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $56,288 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 484 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AGDU
Policy instance	4
Insurance contract or identification number GUC0AGDU Number of Individuals Covered 59 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $2,234 Total amount of fees paid to insurance company USD $1,927 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,338 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,234 Amount paid for insurance broker fees 1927 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0285332
Policy instance	6
Insurance contract or identification number 0285332 Number of Individuals Covered 122 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $313,744 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	1001189
Policy instance	8
Insurance contract or identification number 1001189 Number of Individuals Covered 186 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $1,155 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ORGAN/TISSUE TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,546 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,155 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDU
Policy instance	7
Insurance contract or identification number GUPR0AGDU Number of Individuals Covered 30 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $674 Total amount of fees paid to insurance company USD $531 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,743 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $674 Amount paid for insurance broker fees 531 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDU
Policy instance	9
Insurance contract or identification number GLTD0AGDU Number of Individuals Covered 43 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $707 Total amount of fees paid to insurance company USD $528 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $707 Amount paid for insurance broker fees 528 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDU
Policy instance	1
Insurance contract or identification number GLUG0AGDU Number of Individuals Covered 44 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $1,277 Total amount of fees paid to insurance company USD $990 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,769 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,277 Amount paid for insurance broker fees 990 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDU
Policy instance	2
Insurance contract or identification number GVTL0AGDU Number of Individuals Covered 91 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $2,810 Total amount of fees paid to insurance company USD $2,328 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,098 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,810 Amount paid for insurance broker fees 2328 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLLV0AGDU
Policy instance	5
Insurance contract or identification number GLLV0AGDU Number of Individuals Covered 124 Insurance policy start date 2020-09-01 Insurance policy end date 2021-08-31 Total amount of commissions paid to insurance broker USD $2,213 Total amount of fees paid to insurance company USD $378 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,130 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,213 Amount paid for insurance broker fees 378 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDU
Policy instance	3
Insurance contract or identification number GUPR0AGDU Number of Individuals Covered 35 Insurance policy start date 2020-05-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $236 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,359 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $236 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	1001189
Policy instance	7
Insurance contract or identification number 1001189 Number of Individuals Covered 197 Insurance policy start date 2019-09-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $1,225 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ORGAN/TISSUE TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,225 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AGDU
Policy instance	6
Insurance contract or identification number GUC0AGDU Number of Individuals Covered 66 Insurance policy start date 2020-05-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $807 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $807 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0285332
Policy instance	5
Insurance contract or identification number 0285332 Number of Individuals Covered 134 Insurance policy start date 2019-09-01 Insurance policy end date 2020-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $330,624 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	GLUG0AGDU
Policy instance	4
Insurance contract or identification number GLUG0AGDU Number of Individuals Covered 39 Insurance policy start date 2020-05-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $393 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,932 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $393 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10771-1378
Policy instance	2
Insurance contract or identification number 10771-1378 Number of Individuals Covered 135 Insurance policy start date 2019-09-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $2,403 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,403 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDU
Policy instance	1
Insurance contract or identification number GLTD0AGDU Number of Individuals Covered 38 Insurance policy start date 2020-05-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $204 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,044 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $204 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDU
Policy instance	8
Insurance contract or identification number GVTL0AGDU Number of Individuals Covered 102 Insurance policy start date 2020-05-01 Insurance policy end date 2020-08-31 Total amount of commissions paid to insurance broker USD $920 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,201 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $920 Insurance broker organization code? 3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	13318
Policy instance	5
Insurance contract or identification number 13318 Number of Individuals Covered 72 Insurance policy start date 2018-09-01 Insurance policy end date 2019-08-31 Total amount of commissions paid to insurance broker USD $4,765 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER/ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,400 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,041 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDU
Policy instance	2
Insurance contract or identification number GUPR0AGDU Number of Individuals Covered 34 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $879 Total amount of fees paid to insurance company USD $667 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,784 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $726 Amount paid for insurance broker fees 667 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDU
Policy instance	1
Insurance contract or identification number GLTD0AGDU Number of Individuals Covered 38 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $720 Total amount of fees paid to insurance company USD $511 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $593 Amount paid for insurance broker fees 511 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0285332
Policy instance	3
Insurance contract or identification number 0285332 Number of Individuals Covered 157 Insurance policy start date 2018-09-01 Insurance policy end date 2019-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $283,448 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	GUC0AGDU
Policy instance	7
Insurance contract or identification number GUC0AGDU Number of Individuals Covered 66 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $2,930 Total amount of fees paid to insurance company USD $2,221 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $29,297 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,391 Amount paid for insurance broker fees 2221 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDU
Policy instance	9
Insurance contract or identification number GVTL0AGDU Number of Individuals Covered 89 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $3,345 Total amount of fees paid to insurance company USD $2,428 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $33,444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,783 Amount paid for insurance broker fees 2428 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDU
Policy instance	8
Insurance contract or identification number GLUG0AGDU Number of Individuals Covered 39 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $1,326 Total amount of fees paid to insurance company USD $936 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,265 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,089 Amount paid for insurance broker fees 936 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	920116
Policy instance	4
Insurance contract or identification number 920116 Number of Individuals Covered 191 Insurance policy start date 2018-09-01 Insurance policy end date 2019-08-31 Total amount of commissions paid to insurance broker USD $8,396 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $83,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,071 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10771-1378
Policy instance	6
Insurance contract or identification number 10771-1378 Number of Individuals Covered 171 Insurance policy start date 2018-09-01 Insurance policy end date 2019-08-31 Total amount of commissions paid to insurance broker USD $2,846 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,238 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,389 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AGDU
Policy instance	2
Insurance contract or identification number GUPR0AGDU Number of Individuals Covered 49 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $914 Total amount of fees paid to insurance company USD $512 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,143 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $914 Amount paid for insurance broker fees 512 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	920116
Policy instance	8
Insurance contract or identification number 920116 Number of Individuals Covered 196 Insurance policy start date 2017-09-01 Insurance policy end date 2018-08-31 Total amount of commissions paid to insurance broker USD $9,855 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $98,702 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,855 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AGDU
Policy instance	7
Insurance contract or identification number GLTD0AGDU Number of Individuals Covered 46 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $733 Total amount of fees paid to insurance company USD $361 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,334 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $733 Amount paid for insurance broker fees 361 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AGDU
Policy instance	6
Insurance contract or identification number GVTL0AGDU Number of Individuals Covered 133 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $3,493 Total amount of fees paid to insurance company USD $1,771 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $34,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,493 Amount paid for insurance broker fees 1771 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AGDU
Policy instance	5
Insurance contract or identification number GLUG0AGDU Number of Individuals Covered 46 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $1,393 Total amount of fees paid to insurance company USD $691 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,929 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,393 Amount paid for insurance broker fees 691 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0285332
Policy instance	4
Insurance contract or identification number 0285332 Number of Individuals Covered 159 Insurance policy start date 2017-09-01 Insurance policy end date 2018-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $238,231 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	GUC0AGDU
Policy instance	1
Insurance contract or identification number GUC0AGDU Number of Individuals Covered 91 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $2,812 Total amount of fees paid to insurance company USD $1,329 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,117 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,812 Amount paid for insurance broker fees 1329 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10771-1378
Policy instance	3
Insurance contract or identification number 10771-1378 Number of Individuals Covered 160 Insurance policy start date 2018-08-01 Insurance policy end date 2018-08-31 Total amount of commissions paid to insurance broker USD $6,149 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,051 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,149 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	10771-1378
Policy instance	8
Insurance contract or identification number 10771-1378 Number of Individuals Covered 160 Insurance policy start date 2017-08-01 Insurance policy end date 2017-08-31 Total amount of commissions paid to insurance broker USD $512 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,338 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	GVTL 0AGDU
Policy instance	7
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 155 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $3,894 Total amount of fees paid to insurance company USD $1,984 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,939 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	GLUG 0AGDU
Policy instance	5
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 43 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $1,388 Total amount of fees paid to insurance company USD $714 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,879 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0285332
Policy instance	4
Insurance contract or identification number 0285332 Number of Individuals Covered 154 Insurance policy start date 2016-09-01 Insurance policy end date 2017-08-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $224,161 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	GUC 0AGDU
Policy instance	2
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 99 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $2,964 Total amount of fees paid to insurance company USD $1,510 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $29,639 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	GLTD 0AGDU
Policy instance	1
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 42 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $745 Total amount of fees paid to insurance company USD $381 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,451 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	920116
Policy instance	3
Insurance contract or identification number 920116 Number of Individuals Covered 206 Insurance policy start date 2016-09-01 Insurance policy end date 2017-08-31 Total amount of commissions paid to insurance broker USD $12,211 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $93,751 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	GUPR 0AGDU
Policy instance	6
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 81 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $1,304 Total amount of fees paid to insurance company USD $640 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,040 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	SSL-IHCRS-00391
Policy instance	1
Insurance contract or identification number SSL-IHCRS-00391 Number of Individuals Covered 319 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $34,063 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $227,093 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,063 Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	2
Insurance contract or identification number 10775-1045 Number of Individuals Covered 162 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,884 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,642 Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR 0AGDU
Policy instance	3
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 48 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $841 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,412 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $762 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL 0AGDU
Policy instance	4
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 111 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $3,612 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $36,120 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,296 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5911097
Policy instance	5
Insurance contract or identification number 5911097 Number of Individuals Covered 252 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $7,887 Total amount of fees paid to insurance company USD $328 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $80,928 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,853 Amount paid for insurance broker fees 308 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG 0AGDU
Policy instance	6
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 45 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $1,399 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,990 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,281 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD 0AGDU
Policy instance	8
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 45 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $770 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,706 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $705 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	947-1510
Policy instance	9
Insurance contract or identification number 947-1510 Number of Individuals Covered 143 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $2,054 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,054 Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AGDU
Policy instance	7
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 56 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $2,223 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,231 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,017 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5911097
Policy instance	9
Insurance contract or identification number 5911097 Number of Individuals Covered 267 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $8,482 Total amount of fees paid to insurance company USD $1,046 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,668 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,860 Amount paid for insurance broker fees 999 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG 0AGDU
Policy instance	8
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 46 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $1,405 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,054 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,405 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AGDU
Policy instance	1
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 66 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $2,321 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,207 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,321 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	SSL-IHCRS-00391
Policy instance	2
Insurance contract or identification number SSL-IHCRS-00391 Number of Individuals Covered 133 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $33,335 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $222,239 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,335 Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD 0AGDU
Policy instance	3
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 46 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $775 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,749 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $775 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL 0AGDU
Policy instance	4
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 117 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $3,684 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $36,842 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,684 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	6
Insurance contract or identification number 10775-1045 Number of Individuals Covered 164 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $2,007 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,072 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,007 Insurance broker organization code? 3 Insurance broker name ALAMO INSURANCE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR 0AGDU
Policy instance	5
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 57 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $910 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,099 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $910 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	947-0078
Policy instance	7
Insurance contract or identification number 947-0078 Number of Individuals Covered 133 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $1,894 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,894 Insurance broker organization code? 3 Insurance broker name SWBC LIFE INSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD 0AGDU
Policy instance	3
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 47 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $784 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,841 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $784 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG 0AGDU
Policy instance	1
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 47 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $1,447 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,447 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	223277
Policy instance	2
Insurance contract or identification number 223277 Number of Individuals Covered 158 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $1,440 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,259 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,440 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	SSL-IHCRS-00391
Policy instance	9
Insurance contract or identification number SSL-IHCRS-00391 Number of Individuals Covered 119 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $32,055 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $213,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,055 Insurance broker organization code? 3 Insurance broker name ALAMO INSURANCE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL 0AGDU
Policy instance	8
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 127 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $3,899 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,988 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,899 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	4
Insurance contract or identification number 10775-1045 Number of Individuals Covered 167 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,790 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,899 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,790 Insurance broker organization code? 3 Insurance broker name ALAMO INSURANCE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR 0AGDU
Policy instance	7
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 54 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $836 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,356 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $836 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	949-6285
Policy instance	6
Insurance contract or identification number 949-6285 Number of Individuals Covered 115 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,682 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,827 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,682 Insurance broker organization code? 3 Insurance broker name ALAMO INSURANCE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AGDU
Policy instance	5
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 70 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $2,262 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,620 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,262 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7313018
Policy instance	8
Insurance contract or identification number E7313018 Number of Individuals Covered 75 Insurance policy start date 2011-10-01 Insurance policy end date 2012-09-30 Total amount of commissions paid to insurance broker USD $2,877 Total amount of fees paid to insurance company USD $793 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER/CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,034 Insurance broker organization code? 3 Amount paid for insurance broker fees 329 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name ELIZABETH ROBERTS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AGDU
Policy instance	9
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 84 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $2,445 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,450 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,445 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	949-3550
Policy instance	10
Insurance contract or identification number 949-3550 Number of Individuals Covered 119 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,569 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,569 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	AULM1089-C
Policy instance	1
Insurance contract or identification number AULM1089-C Number of Individuals Covered 119 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $25,695 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $171,304 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,695 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR 0AGDU
Policy instance	7
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 64 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $876 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,764 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $876 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL 0AGDU
Policy instance	6
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 131 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $4,151 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $41,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,151 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	5
Insurance contract or identification number 10775-1045 Number of Individuals Covered 176 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $2,199 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,990 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,199 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD 0AGDU
Policy instance	2
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 44 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $788 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,881 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $788 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	223277
Policy instance	4
Insurance contract or identification number 223277 Number of Individuals Covered 176 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $1,634 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,964 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,634 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG 0AGDU
Policy instance	3
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 44 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $1,329 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,287 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,329 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN LONE STAR INSURANCE
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	AULM1089-C
Policy instance	1
Insurance contract or identification number AULM1089-C Number of Individuals Covered 128 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $26,003 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $173,357 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	GLUG 0AGDU
Policy instance	10
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 40 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $1,088 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,883 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7313018
Policy instance	7
Insurance contract or identification number E7313018 Number of Individuals Covered 77 Insurance policy start date 2010-10-01 Insurance policy end date 2011-09-30 Total amount of commissions paid to insurance broker USD $21,766 Total amount of fees paid to insurance company USD $5,340 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER/CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $46,741 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	GUC 0AGDU
Policy instance	9
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 55 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $2,535 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,353 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number	020-5099-00
Policy instance	8
Insurance contract or identification number 020-5099-00 Number of Individuals Covered 174 Insurance policy start date 2011-03-01 Insurance policy end date 2012-02-29 Total amount of commissions paid to insurance broker USD $2,879 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $58,538 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	GLTD 0AGDU
Policy instance	6
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 40 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $839 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,388 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	4
Insurance contract or identification number 10775-1045 Number of Individuals Covered 179 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $2,004 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,045 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	GVTL 0AGDU
Policy instance	3
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 90 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $4,411 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $44,108 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	949-0553
Policy instance	2
Insurance contract or identification number 949-0553 Number of Individuals Covered 129 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $1,494 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,948 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	GUPR 0AGDU
Policy instance	5
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 39 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $1,154 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,542 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number	020-5099-00
Policy instance	1
Insurance contract or identification number 020-5099-00 Number of Individuals Covered 174 Insurance policy start date 2010-09-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $805 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $34,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AIG (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	280-8992
Policy instance	11
Insurance contract or identification number 280-8992 Number of Individuals Covered 131 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $1,380 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TRANSPLANT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,804 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	GUC 0AGDU
Policy instance	10
Insurance contract or identification number GUC 0AGDU Number of Individuals Covered 91 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $3,249 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $26,993 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	GLTD 0AGDU
Policy instance	9
Insurance contract or identification number GLTD 0AGDU Number of Individuals Covered 39 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $820 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,732 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	8
Insurance contract or identification number 10775-1045 Number of Individuals Covered 159 Insurance policy start date 2009-11-01 Insurance policy end date 2010-10-31 Total amount of commissions paid to insurance broker USD $2,059 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,597 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	10775-1045
Policy instance	7
Insurance contract or identification number 10775-1045 Number of Individuals Covered 181 Insurance policy start date 2010-11-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $1,560 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,599 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number	020-5099-00
Policy instance	6
Insurance contract or identification number 020-5099-00 Number of Individuals Covered 174 Insurance policy start date 2009-09-01 Insurance policy end date 2010-08-31 Total amount of commissions paid to insurance broker USD $3,471 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $52,023 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	GLUG 0AGDU
Policy instance	4
Insurance contract or identification number GLUG 0AGDU Number of Individuals Covered 40 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $1,069 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,788 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	AULM1044
Policy instance	3
Insurance contract or identification number AULM1044 Number of Individuals Covered 133 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $27,621 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $184,142 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	GVTL 0AGDU
Policy instance	2
Insurance contract or identification number GVTL 0AGDU Number of Individuals Covered 126 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $4,082 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $33,013 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	GUPR 0AGDU
Policy instance	5
Insurance contract or identification number GUPR 0AGDU Number of Individuals Covered 84 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $1,299 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,138 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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• UNITED FASHIONS OF TEXAS, LTD. WELFARE BENEFITS PLAN [EIN = 742715850]