401k Plan data: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN plan

COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN
Plan identification number	501

COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING has sponsored the creation of one or more 401k plans.

Company Name: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING

Employer identification number (EIN): 262863088

NAIC Classification: 424800

Additional information about COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division

Incorporation Date: 2008-06-20

Company Identification Number: 52887594

Legal Registered Office Address: 1127 BROADWAY STREET NE STE 310

SALEM
United States of America (USA)
97301

More information about COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 PAUL MEADE PAUL MEADE 2019-07-19
501 2017-01-01 PAUL MEADE PAUL MEADE 2018-07-23
501 2016-01-01 PAUL MEADE PAUL MEADE 2017-07-25
501 2015-01-01 PAUL MEADE PAUL MEADE 2016-07-13
501 2014-01-01 PAUL MEADE PAUL MEADE 2015-06-19
501 2013-01-01 PAUL MEADE PAUL MEADE 2014-07-08
501 2012-01-01 PAUL MEADE PAUL MEADE 2013-06-10
501 2011-01-01 PAUL MEADE PAUL MEADE 2012-06-04
501 2009-01-01 PAUL MEADE PAUL MEADE 2010-07-20

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01	PAUL MEADE	PAUL MEADE	2019-07-19
501	2017-01-01	PAUL MEADE	PAUL MEADE	2018-07-23
501	2016-01-01	PAUL MEADE	PAUL MEADE	2017-07-25
501	2015-01-01	PAUL MEADE	PAUL MEADE	2016-07-13
501	2014-01-01	PAUL MEADE	PAUL MEADE	2015-06-19
501	2013-01-01	PAUL MEADE	PAUL MEADE	2014-07-08
501	2012-01-01	PAUL MEADE	PAUL MEADE	2013-06-10
501	2011-01-01	PAUL MEADE	PAUL MEADE	2012-06-04
501	2009-01-01	PAUL MEADE	PAUL MEADE	2010-07-20

Plan Statistics for COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN

401k plan membership statisitcs for COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN

Measure Date Value
2022: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,310
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 3,000
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 3,000
2021: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,492
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,310
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 2,310
2020: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,280
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,492
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 2,492
2019: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,188
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,280
Number of retired or separated participants receiving benefits 2019-01-01 619
Number of other retired or separated participants entitled to future benefits 2019-01-01 95
Total of all active and inactive participants 2019-01-01 2,994
2018: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,188
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,280
Number of retired or separated participants receiving benefits 2018-01-01 619
Number of other retired or separated participants entitled to future benefits 2018-01-01 95
Total of all active and inactive participants 2018-01-01 2,994
2017: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,192
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,136
Number of retired or separated participants receiving benefits 2017-01-01 26
Number of other retired or separated participants entitled to future benefits 2017-01-01 98
Total of all active and inactive participants 2017-01-01 2,260
2016: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,607
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,092
Number of retired or separated participants receiving benefits 2016-01-01 30
Number of other retired or separated participants entitled to future benefits 2016-01-01 89
Total of all active and inactive participants 2016-01-01 2,211
2015: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 3,032
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 3,032
Number of retired or separated participants receiving benefits 2015-01-01 24
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 3,056
2014: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 2,258
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 2,258
Number of retired or separated participants receiving benefits 2014-01-01 4
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 2,262
2013: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,893
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,942
Total of all active and inactive participants 2013-01-01 1,942
2012: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,819
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,893
Total of all active and inactive participants 2012-01-01 1,893
2011: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,885
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,819
Total of all active and inactive participants 2011-01-01 1,819
2009: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,548
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,848
Total of all active and inactive participants 2009-01-01 1,848

Measure	Date	Value
2022: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,310
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	3,000
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	3,000
2021: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,492
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,310
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	2,310
2020: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,280
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,492
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	2,492
2019: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,188
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,280
Number of retired or separated participants receiving benefits	2019-01-01	619
Number of other retired or separated participants entitled to future benefits	2019-01-01	95
Total of all active and inactive participants	2019-01-01	2,994
2018: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,188
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,280
Number of retired or separated participants receiving benefits	2018-01-01	619
Number of other retired or separated participants entitled to future benefits	2018-01-01	95
Total of all active and inactive participants	2018-01-01	2,994
2017: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,192
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,136
Number of retired or separated participants receiving benefits	2017-01-01	26
Number of other retired or separated participants entitled to future benefits	2017-01-01	98
Total of all active and inactive participants	2017-01-01	2,260
2016: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,607
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,092
Number of retired or separated participants receiving benefits	2016-01-01	30
Number of other retired or separated participants entitled to future benefits	2016-01-01	89
Total of all active and inactive participants	2016-01-01	2,211
2015: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,032
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	3,032
Number of retired or separated participants receiving benefits	2015-01-01	24
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	3,056
2014: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	2,258
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	2,258
Number of retired or separated participants receiving benefits	2014-01-01	4
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	2,262
2013: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,893
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,942
Total of all active and inactive participants	2013-01-01	1,942
2012: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,819
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,893
Total of all active and inactive participants	2012-01-01	1,893
2011: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,885
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,819
Total of all active and inactive participants	2011-01-01	1,819
2009: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,548
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,848
Total of all active and inactive participants	2009-01-01	1,848

Form 5500 Responses for COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN

2022: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING HEALTH & WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2315
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $1,009
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1009
Additional information about fees paid to insurance broker	GEN AGENCY FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	919
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,583
Total amount of fees paid to insurance company	USD $9,583
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $209,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,583
Insurance broker organization code?	3
Amount paid for insurance broker fees	9583
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2315
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $4,074
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4074
Additional information about fees paid to insurance broker	GEN AGENCY FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	614
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $-225
Total amount of fees paid to insurance company	USD $8,700
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $184,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-225
Amount paid for insurance broker fees	8700
Additional information about fees paid to insurance broker	GENERAL ADMIN FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $645
Total amount of fees paid to insurance company	USD $213
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $645
Insurance broker organization code?	3
Amount paid for insurance broker fees	213
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	95
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $438
Total amount of fees paid to insurance company	USD $219
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $438
Insurance broker organization code?	3
Amount paid for insurance broker fees	219
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	1070
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,757
Total amount of fees paid to insurance company	USD $3,007
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $65,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,757
Insurance broker organization code?	3
Amount paid for insurance broker fees	3007
Additional information about fees paid to insurance broker	GEN AGENCY FEES

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-015420-000

Policy instance

Insurance contract or identification number	16-015420-000
Number of Individuals Covered	1787
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $139,424
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,686,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	139424
Additional information about fees paid to insurance broker	ADMIN FEES GROUP VOLUME BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30093361

Policy instance

Insurance contract or identification number	30093361
Number of Individuals Covered	1636
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

479663

Policy instance

Insurance contract or identification number	479663
Number of Individuals Covered	910
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,276
Total amount of fees paid to insurance company	USD $4,773
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,276
Amount paid for insurance broker fees	4773
Additional information about fees paid to insurance broker	ADDITIONAL COMP
Insurance broker organization code?	3

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

COLUMBIA

Policy instance

Insurance contract or identification number	COLUMBIA
Number of Individuals Covered	3000
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $64,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,502
Total amount of fees paid to insurance company	USD $1,104
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,502
Insurance broker organization code?	3
Amount paid for insurance broker fees	1104
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	623
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $9,276
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9276
Additional information about fees paid to insurance broker	GENERAL ADMIN FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2310
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $4,470
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4470
Additional information about fees paid to insurance broker	GEN AGENCY FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	865
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,738
Total amount of fees paid to insurance company	USD $10,738
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $214,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,738
Insurance broker organization code?	3
Amount paid for insurance broker fees	10738
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	80
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $182
Total amount of fees paid to insurance company	USD $132
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Insurance broker organization code?	3
Amount paid for insurance broker fees	132
Additional information about fees paid to insurance broker	GEN AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2316
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $1,107
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1107
Additional information about fees paid to insurance broker	GEN AGENCY FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	1060
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,660
Total amount of fees paid to insurance company	USD $3,384
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,660
Insurance broker organization code?	3
Amount paid for insurance broker fees	3384
Additional information about fees paid to insurance broker	GEN AGENCY FEES

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

Policy contract number

E5039276

Policy instance

Insurance contract or identification number	E5039276
Number of Individuals Covered	932
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $43,981
Total amount of fees paid to insurance company	USD $9,667
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $233,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,206
Amount paid for insurance broker fees	6256
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

15090635

Policy instance

Insurance contract or identification number	15090635
Number of Individuals Covered	2800
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $38,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30093361

Policy instance

Insurance contract or identification number	30093361
Number of Individuals Covered	1617
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

919707

Policy instance

Insurance contract or identification number	919707
Number of Individuals Covered	2099
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $137,805
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,033,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137,805
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,743
Total amount of fees paid to insurance company	USD $720
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,743
Insurance broker organization code?	3
Amount paid for insurance broker fees	670
Additional information about fees paid to insurance broker	SALES AND SERVICE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	630
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $8,345
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7238
Additional information about fees paid to insurance broker	GENERAL ADMIN FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2492
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $4,398
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3525
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES AND SERVICE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	959
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,315
Total amount of fees paid to insurance company	USD $11,060
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $194,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,315
Insurance broker organization code?	3
Amount paid for insurance broker fees	8990

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	62
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $488
Total amount of fees paid to insurance company	USD $167
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $488
Insurance broker organization code?	3
Amount paid for insurance broker fees	103
Additional information about fees paid to insurance broker	SALES AND SERVICE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2498
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $1,092
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $19,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	873
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	912
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,592
Total amount of fees paid to insurance company	USD $3,170
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $56,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,592
Insurance broker organization code?	3
Amount paid for insurance broker fees	2532
Additional information about fees paid to insurance broker	SALES AND SERVICE

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

Policy contract number

E5039276

Policy instance

Insurance contract or identification number	E5039276
Number of Individuals Covered	1070
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $69,736
Total amount of fees paid to insurance company	USD $21,082
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $256,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,677
Amount paid for insurance broker fees	13687
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

919707

Policy instance

Insurance contract or identification number	919707
Number of Individuals Covered	2099
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $150,536
Total amount of fees paid to insurance company	USD $18,750
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,732,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $150,536
Amount paid for insurance broker fees	18750
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30093361

Policy instance

Insurance contract or identification number	30093361
Number of Individuals Covered	1770
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

15090635

Policy instance

Insurance contract or identification number	15090635
Number of Individuals Covered	2800
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $42,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	311
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,771
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,771
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	382
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2561
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	1074
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,299
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,299
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

10130121001

Policy instance

Insurance contract or identification number	10130121001
Number of Individuals Covered	3368
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	56
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $413
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $413
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2561
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	912
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,487
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $54,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,487
Insurance broker organization code?	3

INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

15090635

Policy instance

Insurance contract or identification number	15090635
Number of Individuals Covered	2800
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $43,250
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

E5039276

Policy instance

Insurance contract or identification number	E5039276
Number of Individuals Covered	910
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $96,119
Total amount of fees paid to insurance company	USD $77,529
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $210,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,409
Amount paid for insurance broker fees	50800
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

919707

Policy instance

Insurance contract or identification number	919707
Number of Individuals Covered	1842
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $122,054
Total amount of fees paid to insurance company	USD $25,000
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,441,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $122,054
Amount paid for insurance broker fees	25000
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

10162801001

Policy instance

Insurance contract or identification number	10162801001
Number of Individuals Covered	38
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )

Policy contract number

10029786

Policy instance

Insurance contract or identification number	10029786
Number of Individuals Covered	4734
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,256,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

15090635

Policy instance

Insurance contract or identification number	15090635
Number of Individuals Covered	2800
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $42,000
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

E5039276

Policy instance

Insurance contract or identification number	E5039276
Number of Individuals Covered	35
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,559
Total amount of fees paid to insurance company	USD $1,603
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $483
Amount paid for insurance broker fees	979
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	705
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,109
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $45,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,728
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

10130121001

Policy instance

Insurance contract or identification number	10130121001
Number of Individuals Covered	3805
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	1212
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $13,999
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,006
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2890
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	469
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	222
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,820
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,306
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	30
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $720
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $459
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2890
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $23,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	2131
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	615
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,552
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,776
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2655
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	462
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	144
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,484
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,242
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	35
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,564
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,282
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2655
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	324
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,634
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,317
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )

Policy contract number

10029786

Policy instance

Insurance contract or identification number	10029786
Number of Individuals Covered	4315
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,755,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967677

Policy instance

Insurance contract or identification number	OK967677
Number of Individuals Covered	2561
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $308
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	308
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961743

Policy instance

Insurance contract or identification number	VDT961743
Number of Individuals Covered	86
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,814
Total amount of fees paid to insurance company	USD $1,439
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,407
Insurance broker organization code?	3
Amount paid for insurance broker fees	1439
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961655

Policy instance

Insurance contract or identification number	VDT961655
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,108
Total amount of fees paid to insurance company	USD $299
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,054
Insurance broker organization code?	3
Amount paid for insurance broker fees	299
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	MATTECHECK & ASSOCIATES

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	2043
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,456
Welfare Benefit Premiums Paid to Carrier	USD $939,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,456
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966128

Policy instance

Insurance contract or identification number	FLX966128
Number of Individuals Covered	2561
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $1,230
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1230
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX966129

Policy instance

Insurance contract or identification number	FLX966129
Number of Individuals Covered	600
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,810
Total amount of fees paid to insurance company	USD $3,136
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,905
Insurance broker organization code?	3
Amount paid for insurance broker fees	3136
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	MATTECHECK & ASSOCIATES

LIFEWISE HEALTH PLAN OF OREGON, INC. (National Association of Insurance Commissioners NAIC id number: 84930 )

Policy contract number

1035369 WA

Policy instance

Insurance contract or identification number	1035369 WA
Number of Individuals Covered	621
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $390,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967678

Policy instance

Insurance contract or identification number	OK967678
Number of Individuals Covered	288
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,926
Total amount of fees paid to insurance company	USD $280
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $963
Insurance broker organization code?	3
Amount paid for insurance broker fees	280
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	MATTECHECK & ASSOCIATES

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	2067
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964209

Policy instance

Insurance contract or identification number	LK964209
Number of Individuals Covered	433
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $1,319
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1319
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES

LIFEWISE HEALTH PLAN OF OREGON, INC. (National Association of Insurance Commissioners NAIC id number: 84930 )

Policy contract number

1035369 OR

Policy instance

Insurance contract or identification number	1035369 OR
Number of Individuals Covered	676
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $428,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

94239

Policy instance

Insurance contract or identification number	94239
Number of Individuals Covered	379
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $33,560
Total amount of fees paid to insurance company	USD $1,678
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $223,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,780
Amount paid for insurance broker fees	839
Additional information about fees paid to insurance broker	ADDTL COMP
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

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

Policy contract number

094328

Policy instance

Insurance contract or identification number	094328
Number of Individuals Covered	2258
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $223,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	1897
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,170
Welfare Benefit Premiums Paid to Carrier	USD $775,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,170
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	1966
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

094328

Policy instance

Insurance contract or identification number	094328
Number of Individuals Covered	2171
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $180,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	1910
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,620
Total amount of fees paid to insurance company	USD $2,149
Welfare Benefit Premiums Paid to Carrier	USD $865,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,620
Amount paid for insurance broker fees	2149
Additional information about fees paid to insurance broker	ENHANCED COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	1911
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

94239

Policy instance

Insurance contract or identification number	94239
Number of Individuals Covered	392
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $24,592
Total amount of fees paid to insurance company	USD $1,230
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $163,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,296
Amount paid for insurance broker fees	615
Additional information about fees paid to insurance broker	ADDTL COMP
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	1930
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	1929
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,220
Welfare Benefit Premiums Paid to Carrier	USD $844,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,220
Insurance broker organization code?	3
Insurance broker name	DAVIDSON BENEFITS PLANNING LLC

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

Policy contract number

094328

Policy instance

Insurance contract or identification number	094328
Number of Individuals Covered	2049
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $160,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

094329

Policy instance

Insurance contract or identification number	094329
Number of Individuals Covered	435
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $23,170
Total amount of fees paid to insurance company	USD $579
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $154,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	1819
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,069
Welfare Benefit Premiums Paid to Carrier	USD $801,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

094328

Policy instance

Insurance contract or identification number	094328
Number of Individuals Covered	2075
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $261,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE HEALTH PLAN OF OREGON, INC. (National Association of Insurance Commissioners NAIC id number: 84930 )

Policy contract number

1035369

Policy instance

Insurance contract or identification number	1035369
Number of Individuals Covered	1885
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

094329

Policy instance

Insurance contract or identification number	094329
Number of Individuals Covered	424
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $25,206
Total amount of fees paid to insurance company	USD $1,240
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $165,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,603
Amount paid for insurance broker fees	1240
Additional information about fees paid to insurance broker	ADDTL COMP
Insurance broker organization code?	3
Insurance broker name	MATTECHECK & ASSOCIATES INC

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

Policy contract number

094328

Policy instance

Insurance contract or identification number	094328
Number of Individuals Covered	1983
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $270,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12326640

Policy instance

Insurance contract or identification number	12326640
Number of Individuals Covered	1925
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )

Policy contract number

OR535369-9999

Policy instance

Insurance contract or identification number	OR535369-9999
Number of Individuals Covered	1849
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Welfare Benefit Premiums Paid to Carrier	USD $808,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	COHO DISTRIBUTING LLC DBA COLUMBIA DISTRIBUTING
Employer identification number (EIN):	262863088
NAIC Classification:	424800

Jurisdiction of Incorporation:	Oregon Secretary of State Corporations Division
Incorporation Date:	2008-06-20
Company Identification Number:	52887594
Legal Registered Office Address:	1127 BROADWAY STREET NE STE 310 SALEM United States of America (USA) 97301