401k Plan data: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN plan

SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

SIMONMED has sponsored the creation of one or more 401k plans.

Company Name: SIMONMED

Employer identification number (EIN): 264000683

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01
501 2021-06-01
501 2020-06-01
501 2019-06-01
501 2018-06-01
501 2017-06-01 THOMAS W BEAL
501 2016-06-01 THOMAS W. BEAL
501 2015-06-01 THOMAS W. BEAL
501 2014-06-01 THOMAS W. BEAL
501 2013-06-01 THOMAS W. BEAL
501 2012-06-01 THOMAS W. BEAL
501 2011-07-01 THOMAS W BEAL
501 2010-06-01 THOMAS W BEAL

Plan Statistics for SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 2,572
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 2,019
Number of retired or separated participants receiving benefits 2022-06-01 8
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 2,027
Total participants 2022-06-01 2,027
2021: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 1,739
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 2,566
Number of retired or separated participants receiving benefits 2021-06-01 6
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 2,572
Total participants 2021-06-01 2,572
2020: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 1,643
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 1,739
Total of all active and inactive participants 2020-06-01 1,739
Total participants 2020-06-01 1,739
2019: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 1,739
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 1,643
Total of all active and inactive participants 2019-06-01 1,643
Total participants 2019-06-01 1,643
2018: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 1,662
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 1,739
Total of all active and inactive participants 2018-06-01 1,739
Total participants 2018-06-01 1,739
2017: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 707
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 1,662
Total of all active and inactive participants 2017-06-01 1,662
Total participants 2017-06-01 1,662
2016: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 1,013
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 707
Total of all active and inactive participants 2016-06-01 707
Total participants 2016-06-01 707
2015: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 551
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 1,013
Total of all active and inactive participants 2015-06-01 1,013
Total participants 2015-06-01 0
2014: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 505
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 551
Total of all active and inactive participants 2014-06-01 551
Total participants 2014-06-01 0
2013: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 557
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 505
Total of all active and inactive participants 2013-06-01 505
Total participants 2013-06-01 0
2012: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 579
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 557
Total of all active and inactive participants 2012-06-01 557
Total participants 2012-06-01 0
2011: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 613
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 579
Total of all active and inactive participants 2011-07-01 579
Total participants 2011-07-01 579
2010: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-06-01 613
Total number of active participants reported on line 7a of the Form 5500 2010-06-01 613
Total of all active and inactive participants 2010-06-01 613
Total participants 2010-06-01 613

Measure	Date	Value
2022: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	2,572
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	2,019
Number of retired or separated participants receiving benefits	2022-06-01	8
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	2,027
Total participants	2022-06-01	2,027
2021: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	1,739
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	2,566
Number of retired or separated participants receiving benefits	2021-06-01	6
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	2,572
Total participants	2021-06-01	2,572
2020: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	1,643
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	1,739
Total of all active and inactive participants	2020-06-01	1,739
Total participants	2020-06-01	1,739
2019: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	1,739
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	1,643
Total of all active and inactive participants	2019-06-01	1,643
Total participants	2019-06-01	1,643
2018: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	1,662
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	1,739
Total of all active and inactive participants	2018-06-01	1,739
Total participants	2018-06-01	1,739
2017: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	707
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	1,662
Total of all active and inactive participants	2017-06-01	1,662
Total participants	2017-06-01	1,662
2016: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	1,013
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	707
Total of all active and inactive participants	2016-06-01	707
Total participants	2016-06-01	707
2015: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	551
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	1,013
Total of all active and inactive participants	2015-06-01	1,013
Total participants	2015-06-01	0
2014: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	505
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	551
Total of all active and inactive participants	2014-06-01	551
Total participants	2014-06-01	0
2013: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	557
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	505
Total of all active and inactive participants	2013-06-01	505
Total participants	2013-06-01	0
2012: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	579
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	557
Total of all active and inactive participants	2012-06-01	557
Total participants	2012-06-01	0
2011: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	613
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	579
Total of all active and inactive participants	2011-07-01	579
Total participants	2011-07-01	579
2010: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-06-01	613
Total number of active participants reported on line 7a of the Form 5500	2010-06-01	613
Total of all active and inactive participants	2010-06-01	613
Total participants	2010-06-01	613

Form 5500 Responses for SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN

2022: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2018: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: SMI IMAGING LLC - EMPLOYEE WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-06-01	Type of plan entity	Single employer plan
2010-06-01	First time form 5500 has been submitted	Yes
2010-06-01	Plan funding arrangement – Insurance	Yes
2010-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068552

Policy instance

Insurance contract or identification number	NYD068552
Number of Individuals Covered	10
Insurance policy start date	2022-03-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $69
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 $571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69
Amount paid for insurance broker fees	0

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	1603
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,597
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 $65,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,075
Amount paid for insurance broker fees	0
Insurance broker organization code?	5

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0183586

Policy instance

Insurance contract or identification number	0183586
Number of Individuals Covered	1208
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $63,393
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	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 $428,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,535
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00183586

Policy instance

Insurance contract or identification number	00183586
Number of Individuals Covered	1270
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $167,320
Total amount of fees paid to insurance company	USD $7,045
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	Yes
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 $1,252,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,640
Amount paid for insurance broker fees	7045
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION PAYMENTS

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	2177
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,319
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
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 $34,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,319
Amount paid for insurance broker fees	0

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	1017
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,442
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 $53,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,442
Amount paid for insurance broker fees	0

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	2168
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,302
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,302
Amount paid for insurance broker fees	0

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	260
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,327
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 $20,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,327
Amount paid for insurance broker fees	0

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	1328
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $9,773
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 $108,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,773
Amount paid for insurance broker fees	0

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0183586

Policy instance

Insurance contract or identification number	0183586
Number of Individuals Covered	1002
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $68,801
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 $466,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,801
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00183586

Policy instance

Insurance contract or identification number	00183586
Number of Individuals Covered	1162
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $373,730
Total amount of fees paid to insurance company	USD $7,986
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	Yes
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 $1,487,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $373,730
Amount paid for insurance broker fees	7986
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION PAYMENTS

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $20,947
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
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 $167,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $20,947
Amount paid for insurance broker fees	0

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $32,310
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 $258,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $32,310
Amount paid for insurance broker fees	0

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068552

Policy instance

Insurance contract or identification number	NYD068552
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	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 $-112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
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	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 $88,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068552

Policy instance

Insurance contract or identification number	NYD068552
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	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 $1,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
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
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	954
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $8,044
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,044
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	756
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $53,402
Total amount of fees paid to insurance company	USD $3,155
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $351,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,402
Amount paid for insurance broker fees	3155
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00183586

Policy instance

Insurance contract or identification number	00183586
Number of Individuals Covered	857
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $316,995
Total amount of fees paid to insurance company	USD $11,486
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,196,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $316,995
Amount paid for insurance broker fees	9286
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	1739
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $8,012
Total amount of fees paid to insurance company	USD $4,489
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,012
Amount paid for insurance broker fees	4489
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	787
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $13,507
Total amount of fees paid to insurance company	USD $15,000
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,507
Amount paid for insurance broker fees	15000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	147
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $4,710
Total amount of fees paid to insurance company	USD $2,822
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,710
Amount paid for insurance broker fees	2822
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	1739
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $1,113
Total amount of fees paid to insurance company	USD $700
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $7,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,113
Amount paid for insurance broker fees	700
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068552

Policy instance

Insurance contract or identification number	NYD068552
Number of Individuals Covered	10
Insurance policy start date	2020-03-01
Insurance policy end date	2021-03-01
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $72
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67
Amount paid for insurance broker fees	72
Additional information about fees paid to insurance broker	OVERRIDE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	754
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $41,584
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $422,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,498
Insurance broker organization code?	3

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	981
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $10,193
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,193
Insurance broker organization code?	3

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	1643
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $24,976
Total amount of fees paid to insurance company	USD $1,480
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $166,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,976
Amount paid for insurance broker fees	1480
Additional information about fees paid to insurance broker	SALES AND SERVICE OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	153
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $14,098
Total amount of fees paid to insurance company	USD $903
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,098
Amount paid for insurance broker fees	903
Additional information about fees paid to insurance broker	SALES, SERVICE AND OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	793
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $69,142
Total amount of fees paid to insurance company	USD $4,532
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $460,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,142
Amount paid for insurance broker fees	4532
Additional information about fees paid to insurance broker	SALES, SERVICE AND OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	1643
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $3,544
Total amount of fees paid to insurance company	USD $206
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $23,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,544
Amount paid for insurance broker fees	206
Additional information about fees paid to insurance broker	SALES & SERVICE OVERRIDES
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	874
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $354,740
Total amount of fees paid to insurance company	USD $9,841
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,250,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209,735
Amount paid for insurance broker fees	9841
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068552

Policy instance

Insurance contract or identification number	NYD068552
Number of Individuals Covered	18
Insurance policy start date	2019-03-01
Insurance policy end date	2020-03-01
Total amount of commissions paid to insurance broker	USD $104
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	834
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $424,818
Total amount of fees paid to insurance company	USD $10,262
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,179,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $424,818
Amount paid for insurance broker fees	10262
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	1739
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $3,563
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $23,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,563
Insurance broker organization code?	3

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	201
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $15,767
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,767
Insurance broker organization code?	3

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	1739
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $78,961
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $526,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,961
Insurance broker organization code?	3

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	1904
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $25,756
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,756
Insurance broker organization code?	3

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	696
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $9,111
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,111
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	825
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $42,929
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $436,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,929
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	823
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $40,753
Total amount of fees paid to insurance company	USD $9,092
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $414,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	712
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $9,282
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,682
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

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	1819
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Total amount of commissions paid to insurance broker	USD $15,459
Total amount of fees paid to insurance company	USD $1,811
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,468
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

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	1662
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Total amount of commissions paid to insurance broker	USD $56,206
Total amount of fees paid to insurance company	USD $5,843
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $374,709
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

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	177
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Total amount of commissions paid to insurance broker	USD $6,973
Total amount of fees paid to insurance company	USD $883
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,182
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

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	1819
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Total amount of commissions paid to insurance broker	USD $2,371
Total amount of fees paid to insurance company	USD $257
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $15,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,127,070
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

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	1013
Total amount of commissions paid to insurance broker	USD $14,082
Total amount of fees paid to insurance company	USD $1,389
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,082
Amount paid for insurance broker fees	1389
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	1013
Total amount of commissions paid to insurance broker	USD $46,026
Total amount of fees paid to insurance company	USD $4,314
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,026
Amount paid for insurance broker fees	4314
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	108
Total amount of commissions paid to insurance broker	USD $6,921
Total amount of fees paid to insurance company	USD $650
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,921
Amount paid for insurance broker fees	650
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	1013
Total amount of commissions paid to insurance broker	USD $1,996
Total amount of fees paid to insurance company	USD $199
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $13,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,996
Amount paid for insurance broker fees	199
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	580
Total amount of commissions paid to insurance broker	USD $248,201
Total amount of fees paid to insurance company	USD $10,436
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $768,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $248,201
Amount paid for insurance broker fees	10436
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	574
Total amount of commissions paid to insurance broker	USD $31,126
Total amount of fees paid to insurance company	USD $927
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $316,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,126
Amount paid for insurance broker fees	927
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	470
Total amount of commissions paid to insurance broker	USD $6,354
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,354
Insurance broker organization code?	3
Insurance broker name	BEAL INSURANCE

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	551
Total amount of commissions paid to insurance broker	USD $12,234
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,234
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	410
Total amount of commissions paid to insurance broker	USD $5,591
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,591
Insurance broker organization code?	3
Insurance broker name	BEAL INSURANCE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	519
Total amount of commissions paid to insurance broker	USD $27,370
Total amount of fees paid to insurance company	USD $7,791
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $277,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,370
Amount paid for insurance broker fees	7791
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	551
Total amount of commissions paid to insurance broker	USD $38,576
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $257,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,576
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	98
Total amount of commissions paid to insurance broker	USD $5,588
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,588
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	551
Total amount of commissions paid to insurance broker	USD $1,752
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,752
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	551
Total amount of commissions paid to insurance broker	USD $201,012
Total amount of fees paid to insurance company	USD $7,791
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $623,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201,012
Amount paid for insurance broker fees	7791
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	407
Total amount of commissions paid to insurance broker	USD $5,590
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,590
Insurance broker organization code?	3
Insurance broker name	BEAL INSURANCE

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	505
Total amount of commissions paid to insurance broker	USD $11,644
Total amount of fees paid to insurance company	USD $2,258
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,644
Amount paid for insurance broker fees	2258
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	469
Total amount of commissions paid to insurance broker	USD $35,236
Total amount of fees paid to insurance company	USD $9,338
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $234,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,236
Amount paid for insurance broker fees	9338
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	469
Total amount of commissions paid to insurance broker	USD $5,916
Total amount of fees paid to insurance company	USD $1,221
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,916
Amount paid for insurance broker fees	1221
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	469
Total amount of commissions paid to insurance broker	USD $1,693
Total amount of fees paid to insurance company	USD $359
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,693
Amount paid for insurance broker fees	359
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	THOMAS WILLIAM BEAL

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	505
Total amount of commissions paid to insurance broker	USD $188,129
Total amount of fees paid to insurance company	USD $5,901
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
Commission paid to Insurance Broker	USD $188,129
Amount paid for insurance broker fees	5901
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION MEMBERSHIP
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

0183586

Policy instance

Insurance contract or identification number	0183586
Number of Individuals Covered	505
Total amount of commissions paid to insurance broker	USD $29,031
Total amount of fees paid to insurance company	USD $10,211
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $294,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,031
Amount paid for insurance broker fees	10211
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THOMAS BEAL

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

Policy contract number

OK 966232

Policy instance

Insurance contract or identification number	OK 966232
Number of Individuals Covered	557
Total amount of commissions paid to insurance broker	USD $1,884
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $12,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,884
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

VDT961132

Policy instance

Insurance contract or identification number	VDT961132
Number of Individuals Covered	557
Total amount of commissions paid to insurance broker	USD $7,214
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,214
Insurance broker name	THOMAS WILLIAM BEAL

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

Policy contract number

FLX964645

Policy instance

Insurance contract or identification number	FLX964645
Number of Individuals Covered	557
Total amount of commissions paid to insurance broker	USD $12,081
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,081
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

11001-1451

Policy instance

Insurance contract or identification number	11001-1451
Number of Individuals Covered	469
Total amount of commissions paid to insurance broker	USD $6,405
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,405
Insurance broker organization code?	3
Insurance broker name	BEAL INSURANCE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	557
Total amount of commissions paid to insurance broker	USD $176,224
Total amount of fees paid to insurance company	USD $10,211
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $176,224
Amount paid for insurance broker fees	10211
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION MEMBERSHIP
Insurance broker organization code?	3
Insurance broker name	THOMAS W BEAL

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

Policy contract number

LK 963268

Policy instance

Insurance contract or identification number	LK 963268
Number of Individuals Covered	557
Total amount of commissions paid to insurance broker	USD $39,950
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $266,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,950
Insurance broker organization code?	3
Insurance broker name	THOMAS WILLIAM BEAL

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	579
Total amount of commissions paid to insurance broker	USD $195,679
Total amount of fees paid to insurance company	USD $8,615
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

183586

Policy instance

Insurance contract or identification number	183586
Number of Individuals Covered	613
Total amount of commissions paid to insurance broker	USD $141,509
Total amount of fees paid to insurance company	USD $8,363
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Was this data useful?

If you found the data here useful, PLEASE HELP US. We are a start-up and believe in making information freely available. By linking to us, posting on twitter, facebook and linkedin about us and generally spreading the word, you'll help us to grow. Our vision is to provide high quality data about the activities of all the companies in the world and where possible make it free to use and view. Finding and integrating data from thousands of data sources is time consuming and needs lots of effort. By simply spreading the word about us, you will help us. Please use the share buttons. It will only take a few seconds of your time. Thanks for helping

Information Disclaimer

The information provided on this website is not advice, endorsement or recommendation
The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
You are free to use the information for your own personal research on the understanding to do so is at your own risk.

See full terms and conditions

Company Name:	SIMONMED
Employer identification number (EIN):	264000683
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)