401k Plan data: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN plan

FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN
Plan identification number	509

FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

FAIRFIELD MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: FAIRFIELD MEDICAL CENTER

Employer identification number (EIN): 310645626

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about FAIRFIELD MEDICAL CENTER

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 1999-10-18

Company Identification Number: 585143

Legal Registered Office Address: 100 S. THIRD STREET
-
COLUMBUS
United States of America (USA)
43215

More information about FAIRFIELD MEDICAL CENTER

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
509 2022-01-01 JOHN R. JANOSO, JR. 2023-05-30
509 2021-01-01
509 2020-01-01 JONATHAN KELLY 2021-10-15
509 2019-01-01
509 2018-01-01
509 2017-01-01 SKY L. GETTYS SKY L. GETTYS 2018-07-10
509 2016-01-01 SKY L. GETTYS SKY L. GETTYS 2017-09-27
509 2015-01-01 SKY L. GETTYS SKY L. GETTYS 2016-07-13
509 2014-01-01 SKY L. GETTYS SKY L. GETTYS 2015-07-16
509 2013-01-01 SKY L. GETTYS SKY L. GETTYS 2014-07-28
509 2012-01-01 SKY L. GETTYS SKY L. GETTYS 2013-07-28
509 2011-01-01 SKY L. GETTYS SKY L. GETTYS 2012-07-27
509 2010-01-01 SKY L. GETTYS SKY L. GETTYS 2011-07-21
509 2009-01-01 SKY L. GETTYS SKY L. GETTYS 2010-07-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
509	2022-01-01	JOHN R. JANOSO, JR.	2023-05-30
509	2021-01-01
509	2020-01-01	JONATHAN KELLY	2021-10-15
509	2019-01-01
509	2018-01-01
509	2017-01-01	SKY L. GETTYS		SKY L. GETTYS	2018-07-10
509	2016-01-01	SKY L. GETTYS		SKY L. GETTYS	2017-09-27
509	2015-01-01	SKY L. GETTYS		SKY L. GETTYS	2016-07-13
509	2014-01-01	SKY L. GETTYS		SKY L. GETTYS	2015-07-16
509	2013-01-01	SKY L. GETTYS		SKY L. GETTYS	2014-07-28
509	2012-01-01	SKY L. GETTYS		SKY L. GETTYS	2013-07-28
509	2011-01-01	SKY L. GETTYS		SKY L. GETTYS	2012-07-27
509	2010-01-01	SKY L. GETTYS		SKY L. GETTYS	2011-07-21
509	2009-01-01	SKY L. GETTYS		SKY L. GETTYS	2010-07-27

Plan Statistics for FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN

Measure Date Value
2022: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 3,007
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,968
Number of retired or separated participants receiving benefits 2022-01-01 18
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 2,986
2021: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 3,158
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,982
Number of retired or separated participants receiving benefits 2021-01-01 18
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 3,000
2020: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,046
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,849
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 1,849
2019: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,852
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,046
Total of all active and inactive participants 2019-01-01 2,046
Total participants 2019-01-01 2,046
2018: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,841
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,852
Total of all active and inactive participants 2018-01-01 1,852
Total participants 2018-01-01 1,852
2017: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,801
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,841
Total of all active and inactive participants 2017-01-01 1,841
Total participants 2017-01-01 1,841
2016: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,671
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,801
Total of all active and inactive participants 2016-01-01 1,801
Total participants 2016-01-01 1,801
2015: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,587
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,671
Total of all active and inactive participants 2015-01-01 1,671
Total participants 2015-01-01 1,671
2014: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,803
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,587
Total of all active and inactive participants 2014-01-01 1,587
Total participants 2014-01-01 1,587
2013: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,518
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,803
Total of all active and inactive participants 2013-01-01 1,803
Total participants 2013-01-01 1,803
2012: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,631
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,518
Total of all active and inactive participants 2012-01-01 1,518
Total participants 2012-01-01 1,518
2011: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,333
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,631
Total of all active and inactive participants 2011-01-01 1,631
Total participants 2011-01-01 1,631
2010: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 1,313
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,333
Total of all active and inactive participants 2010-01-01 1,333
Total participants 2010-01-01 1,333
2009: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,273
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,313
Total of all active and inactive participants 2009-01-01 1,313
Total participants 2009-01-01 1,313

Measure	Date	Value
2022: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	3,007
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,968
Number of retired or separated participants receiving benefits	2022-01-01	18
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	2,986
2021: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	3,158
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,982
Number of retired or separated participants receiving benefits	2021-01-01	18
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	3,000
2020: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,046
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,849
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	1,849
2019: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,852
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,046
Total of all active and inactive participants	2019-01-01	2,046
Total participants	2019-01-01	2,046
2018: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,841
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,852
Total of all active and inactive participants	2018-01-01	1,852
Total participants	2018-01-01	1,852
2017: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,801
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,841
Total of all active and inactive participants	2017-01-01	1,841
Total participants	2017-01-01	1,841
2016: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,671
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,801
Total of all active and inactive participants	2016-01-01	1,801
Total participants	2016-01-01	1,801
2015: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,587
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,671
Total of all active and inactive participants	2015-01-01	1,671
Total participants	2015-01-01	1,671
2014: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,803
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,587
Total of all active and inactive participants	2014-01-01	1,587
Total participants	2014-01-01	1,587
2013: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,518
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,803
Total of all active and inactive participants	2013-01-01	1,803
Total participants	2013-01-01	1,803
2012: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,631
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,518
Total of all active and inactive participants	2012-01-01	1,518
Total participants	2012-01-01	1,518
2011: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,333
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,631
Total of all active and inactive participants	2011-01-01	1,631
Total participants	2011-01-01	1,631
2010: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	1,313
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,333
Total of all active and inactive participants	2010-01-01	1,333
Total participants	2010-01-01	1,333
2009: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,273
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,313
Total of all active and inactive participants	2009-01-01	1,313
Total participants	2009-01-01	1,313

Form 5500 Responses for FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN

2022: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS 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
2010: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: FAIRFIELD MEDICAL CENTER FLEXIBLE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan 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

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

10350

Policy instance

Insurance contract or identification number	10350
Number of Individuals Covered	2860
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $22,495
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,495
Insurance broker organization code?	3

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1019
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $52,158
Total amount of fees paid to insurance company	USD $4,346
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $347,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,158
Amount paid for insurance broker fees	4346
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2278
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $154,378
Total amount of fees paid to insurance company	USD $13,999
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,119,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154,378
Amount paid for insurance broker fees	13999
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	1061
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,020
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,020
Insurance broker organization code?	3

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	127
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,605
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	GROUP LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,605
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

71531-0

Policy instance

Insurance contract or identification number	71531-0
Number of Individuals Covered	4507
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $112,502
Total amount of fees paid to insurance company	USD $39,594
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 $1,311,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112,502
Amount paid for insurance broker fees	4677
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

417008413157

Policy instance

Insurance contract or identification number	417008413157
Number of Individuals Covered	1282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $991,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

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

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	1081
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,327
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	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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,327
Insurance broker organization code?	3

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	120
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,794
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	GROUP LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,794
Insurance broker organization code?	3

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2374
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $219,968
Total amount of fees paid to insurance company	USD $20,047
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,603,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $219,968
Amount paid for insurance broker fees	20047
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1090
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $54,428
Total amount of fees paid to insurance company	USD $4,536
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $362,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,428
Amount paid for insurance broker fees	4536
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

71531-0

Policy instance

Insurance contract or identification number	71531-0
Number of Individuals Covered	3088
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $130,970
Total amount of fees paid to insurance company	USD $29,783
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 $1,107,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130,970
Insurance broker organization code?	3
Amount paid for insurance broker fees	29783
Additional information about fees paid to insurance broker	SERVICE FEE

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2921
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $29,215
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,215
Insurance broker organization code?	3

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

Policy contract number

0211985

Policy instance

Insurance contract or identification number	0211985
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

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

Policy contract number

0211984

Policy instance

Insurance contract or identification number	0211984
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1121
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $48,957
Total amount of fees paid to insurance company	USD $4,080
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $326,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,957
Amount paid for insurance broker fees	4080
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	1075
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,912
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,912
Insurance broker organization code?	3

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	123
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,072
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	GROUP LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,072
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

417007413157

Policy instance

Insurance contract or identification number	417007413157
Number of Individuals Covered	1331
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $45,885
Total amount of fees paid to insurance company	USD $31,285
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,042,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,885
Insurance broker organization code?	3
Amount paid for insurance broker fees	31285
Additional information about fees paid to insurance broker	SERVICE FEE

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2414
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $190,371
Total amount of fees paid to insurance company	USD $17,526
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,064,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $190,371
Amount paid for insurance broker fees	17526
Additional information about fees paid to insurance broker	ADDL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0211987

Policy instance

Insurance contract or identification number	0211987
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	3006
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $30,277
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,277
Insurance broker organization code?	3

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

Policy contract number

0211985

Policy instance

Insurance contract or identification number	0211985
Number of Individuals Covered	557
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $24,974
Total amount of fees paid to insurance company	USD $1,243
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,974
Amount paid for insurance broker fees	1243
Insurance broker organization code?	3

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

Policy contract number

0211984

Policy instance

Insurance contract or identification number	0211984
Number of Individuals Covered	952
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $25,099
Total amount of fees paid to insurance company	USD $1,121
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,099
Amount paid for insurance broker fees	1121
Insurance broker organization code?	3

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1214
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $53,931
Total amount of fees paid to insurance company	USD $4,494
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $386,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,931
Amount paid for insurance broker fees	4494
Insurance broker organization code?	3

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2667
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $235,110
Total amount of fees paid to insurance company	USD $38,550
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,854,939
Commission paid to Insurance Broker	USD $235,110
Amount paid for insurance broker fees	38550
Insurance broker organization code?	3

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	3207
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $29,929
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 $29,929
Insurance broker organization code?	3

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

Policy contract number

0211987

Policy instance

Insurance contract or identification number	0211987
Number of Individuals Covered	215
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $33,253
Total amount of fees paid to insurance company	USD $1,444
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,253
Amount paid for insurance broker fees	1444
Insurance broker organization code?	3

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	129
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,598
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $40,599
Commission paid to Insurance Broker	USD $7,598
Insurance broker organization code?	3

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

Policy contract number

417007413157

Policy instance

Insurance contract or identification number	417007413157
Number of Individuals Covered	1408
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $48,857
Welfare Benefit Premiums Paid to Carrier	USD $1,112,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,857
Additional information about fees paid to insurance broker	MANAGING PRODUCER FEE

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

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	1128
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,604
Vision 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 $5,604
Insurance broker organization code?	3

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	119
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,167
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $35,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,828
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS - COL.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	639
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $80,085
Total amount of fees paid to insurance company	USD $7,339
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $508,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $279
Insurance broker organization code?	3
Amount paid for insurance broker fees	32
Insurance broker name	LA CROIX SYSTEMS INC.

AMERICAN ALTERNATIVE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 19720 )

Policy contract number

10404

Policy instance

Insurance contract or identification number	10404
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Welfare Benefit Premiums Paid to Carrier	USD $710,796
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

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	1633
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $32,285
Total amount of fees paid to insurance company	USD $7,280
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,151,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,918
Insurance broker organization code?	3
Amount paid for insurance broker fees	7280
Insurance broker name	MERCER HEALTH & BENEFITS - COL.

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1128
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $44,693
Total amount of fees paid to insurance company	USD $1,985
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $297,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,877
Insurance broker organization code?	3
Amount paid for insurance broker fees	1985
Insurance broker name	MERCER HEALTH & BENEFITS - COL.

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2953
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $26,181
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 $13,002
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	1039
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,095
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $434,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,285
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2802
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $23,904
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 $23,904
Insurance broker organization code?	3
Insurance broker name	WILLIAM MEYER

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	107
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $5,776
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $26,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,776
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	942
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,290
Vision 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 $6,290
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	860
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $22,278
Total amount of fees paid to insurance company	USD $2,382
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $243,938
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	47
Insurance broker name	IMPELMAN INSURANCE AND INVEST. SER.

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	1092
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $24,791
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $153,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,791
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

AMERICAN ALTERNATIVE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 19720 )

Policy contract number

10404

Policy instance

Insurance contract or identification number	10404
Number of Individuals Covered	1210
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Welfare Benefit Premiums Paid to Carrier	USD $410,255
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

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2907
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $30,821
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,182,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,821
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	319
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $24,795
Total amount of fees paid to insurance company	USD $1,214
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $263,376
Commission paid to Insurance Broker	USD $7,678
Insurance broker organization code?	3
Amount paid for insurance broker fees	223
Insurance broker name	CHARLES D MERS AND ASSOC

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	114
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $8,030
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,625
Commission paid to Insurance Broker	USD $8,030
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2561
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $20,838
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $771,871
Commission paid to Insurance Broker	USD $20,838
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2662
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $23,431
Dental Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $23,431
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY

MUNICH AMERICAN REASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66346 )

Policy contract number

10404

Policy instance

Insurance contract or identification number	10404
Number of Individuals Covered	1144
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Welfare Benefit Premiums Paid to Carrier	USD $381,110

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	454
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $20,511
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $148,913
Commission paid to Insurance Broker	USD $20,511
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	853
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,322
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $5,322
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

LGS00840-12

Policy instance

Insurance contract or identification number	LGS00840-12
Number of Individuals Covered	1227
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Welfare Benefit Premiums Paid to Carrier	USD $345,891

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	454
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $20,511
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $148,913
Commission paid to Insurance Broker	USD $20,511
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	810
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,154
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $5,154
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2661
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $25,202
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $908,058
Commission paid to Insurance Broker	USD $25,202
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	346
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $25,125
Total amount of fees paid to insurance company	USD $2,319
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $276,301
Commission paid to Insurance Broker	USD $7,829
Amount paid for insurance broker fees	529
Insurance broker organization code?	3
Insurance broker name	JEFFERY M. FUQUA

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	114
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $8,030
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,625
Commission paid to Insurance Broker	USD $8,030
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2596
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $23,476
Dental Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $23,476
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2541
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $23,129
Dental Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $23,129
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	399
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $15,765
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $97,550
Commission paid to Insurance Broker	USD $15,765
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2564
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $24,372
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $703,316
Commission paid to Insurance Broker	USD $24,372
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	359
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $39,489
Total amount of fees paid to insurance company	USD $4,269
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $368,266
Commission paid to Insurance Broker	USD $11,430
Insurance broker organization code?	3
Amount paid for insurance broker fees	805
Insurance broker name	JEFFREY M. FUQUA

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	643
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,104
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $5,104
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	119
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $5,787
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $27,102
Commission paid to Insurance Broker	USD $5,787
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

SLC1007

Policy instance

Insurance contract or identification number	SLC1007
Number of Individuals Covered	1155
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Welfare Benefit Premiums Paid to Carrier	USD $272,786

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

SLC834

Policy instance

Insurance contract or identification number	SLC834
Number of Individuals Covered	980
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Welfare Benefit Premiums Paid to Carrier	USD $256,880

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	451
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $19,500
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $135,549

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	382
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $38,392
Total amount of fees paid to insurance company	USD $2,883
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $285,071

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2408
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $24,256
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $744,876

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	678
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,026
Vision Insurance Welfare Benefit	Yes

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	99
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $6,173
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $30,866

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2650
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $22,183
Dental Insurance Welfare Benefit	Yes

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

SLC834

Policy instance

Insurance contract or identification number	SLC834
Number of Individuals Covered	1017
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Welfare Benefit Premiums Paid to Carrier	USD $255,906

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

Policy contract number

121617

Policy instance

Insurance contract or identification number	121617
Number of Individuals Covered	436
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $1,125
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,497
Commission paid to Insurance Broker	USD $1,125
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

579686

Policy instance

Insurance contract or identification number	579686
Number of Individuals Covered	2427
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $23,752
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $625,695
Commission paid to Insurance Broker	USD $23,752
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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

Policy contract number

E7211600

Policy instance

Insurance contract or identification number	E7211600
Number of Individuals Covered	362
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $23,279
Total amount of fees paid to insurance company	USD $409
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $291,217
Commission paid to Insurance Broker	USD $7,182
Insurance broker organization code?	3
Amount paid for insurance broker fees	172
Insurance broker name	JEFFERY FUQUA

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12130297

Policy instance

Insurance contract or identification number	12130297
Number of Individuals Covered	740
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,985
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $4,985
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D6400, D6405

Policy instance

Insurance contract or identification number	D6400, D6405
Number of Individuals Covered	2578
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $21,299
Dental Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $21,299
Insurance broker organization code?	3
Insurance broker name	WILLIAM MEYER

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

Policy contract number

127658

Policy instance

Insurance contract or identification number	127658
Number of Individuals Covered	110
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $6,698
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $30,762
Commission paid to Insurance Broker	USD $6,698
Insurance broker organization code?	3
Insurance broker name	WILLIAM H. MEYER AGENCY, INC.

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Company Name:	FAIRFIELD MEDICAL CENTER
Employer identification number (EIN):	310645626
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	1999-10-18
Company Identification Number:	585143
Legal Registered Office Address:	100 S. THIRD STREET - COLUMBUS United States of America (USA) 43215