401k Plan data: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN plan

PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	PLASKOLITE LIFE AND HEALTH INSURANCE PLAN
Plan identification number	501

PLASKOLITE LIFE AND HEALTH INSURANCE 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

PLASKOLITE, LLC has sponsored the creation of one or more 401k plans.

Company Name: PLASKOLITE, LLC

Employer identification number (EIN): 314376110

NAIC Classification: 326100

Additional information about PLASKOLITE, LLC

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 1950-04-21

Company Identification Number: 217850

Legal Registered Office Address: 1770 JOYCE AVE
-
COLUMBUS
United States of America (USA)
43216

More information about PLASKOLITE, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PLASKOLITE LIFE AND HEALTH INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 TESS SABO 2023-06-23
501 2021-01-01 TESS SABO 2022-07-14
501 2020-01-01 TESS SABO 2021-07-22
501 2019-01-01 TESS SABO 2020-07-07
501 2018-01-01
501 2017-01-01
501 2017-01-01
501 2016-01-01 TESS SABO
501 2015-01-01 JARED LONG
501 2014-01-01 JARED LONG
501 2013-01-01 JARED LONG
501 2012-01-01 JOSHUA C KECK
501 2011-01-01 JOSHUA C KECK
501 2009-01-01 RICHARD J. LARKIN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	TESS SABO	2023-06-23
501	2021-01-01	TESS SABO	2022-07-14
501	2020-01-01	TESS SABO	2021-07-22
501	2019-01-01	TESS SABO	2020-07-07
501	2018-01-01
501	2017-01-01
501	2017-01-01
501	2016-01-01	TESS SABO
501	2015-01-01	JARED LONG
501	2014-01-01	JARED LONG
501	2013-01-01	JARED LONG
501	2012-01-01	JOSHUA C KECK
501	2011-01-01	JOSHUA C KECK
501	2009-01-01	RICHARD J. LARKIN

Plan Statistics for PLASKOLITE LIFE AND HEALTH INSURANCE PLAN

401k plan membership statisitcs for PLASKOLITE LIFE AND HEALTH INSURANCE PLAN

Measure Date Value
2022: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 729
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 752
Number of retired or separated participants receiving benefits 2022-01-01 4
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 756
Number of employers contributing to the scheme 2022-01-01 0
2021: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,036
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 921
Number of retired or separated participants receiving benefits 2021-01-01 12
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 933
Number of employers contributing to the scheme 2021-01-01 0
2020: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 761
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 880
Number of retired or separated participants receiving benefits 2020-01-01 12
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 892
Number of employers contributing to the scheme 2020-01-01 0
2019: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 812
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 761
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 761
Number of employers contributing to the scheme 2019-01-01 0
2018: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 584
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 812
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 812
Number of employers contributing to the scheme 2018-01-01 0
2017: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 572
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 604
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 604
Number of employers contributing to the scheme 2017-01-01 0
2016: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 577
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 613
Number of retired or separated participants receiving benefits 2016-01-01 5
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 618
2015: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 516
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 583
Number of retired or separated participants receiving benefits 2015-01-01 5
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 588
2014: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 485
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 516
Number of retired or separated participants receiving benefits 2014-01-01 5
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 521
2013: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 477
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 525
Number of retired or separated participants receiving benefits 2013-01-01 2
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 527
2012: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 457
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 472
Number of retired or separated participants receiving benefits 2012-01-01 2
Number of other retired or separated participants entitled to future benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 475
2011: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 226
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 223
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 223
2009: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 418
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 409
Number of retired or separated participants receiving benefits 2009-01-01 1
Number of other retired or separated participants entitled to future benefits 2009-01-01 4
Total of all active and inactive participants 2009-01-01 414

Measure	Date	Value
2022: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	729
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	752
Number of retired or separated participants receiving benefits	2022-01-01	4
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	756
Number of employers contributing to the scheme	2022-01-01	0
2021: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,036
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	921
Number of retired or separated participants receiving benefits	2021-01-01	12
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	933
Number of employers contributing to the scheme	2021-01-01	0
2020: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	761
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	880
Number of retired or separated participants receiving benefits	2020-01-01	12
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	892
Number of employers contributing to the scheme	2020-01-01	0
2019: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	812
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	761
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	761
Number of employers contributing to the scheme	2019-01-01	0
2018: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	584
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	812
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	812
Number of employers contributing to the scheme	2018-01-01	0
2017: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	572
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	604
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	604
Number of employers contributing to the scheme	2017-01-01	0
2016: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	577
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	613
Number of retired or separated participants receiving benefits	2016-01-01	5
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	618
2015: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	516
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	583
Number of retired or separated participants receiving benefits	2015-01-01	5
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	588
2014: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	485
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	516
Number of retired or separated participants receiving benefits	2014-01-01	5
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	521
2013: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	477
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	525
Number of retired or separated participants receiving benefits	2013-01-01	2
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	527
2012: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	457
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	472
Number of retired or separated participants receiving benefits	2012-01-01	2
Number of other retired or separated participants entitled to future benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	475
2011: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	226
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	223
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	223
2009: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	418
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	409
Number of retired or separated participants receiving benefits	2009-01-01	1
Number of other retired or separated participants entitled to future benefits	2009-01-01	4
Total of all active and inactive participants	2009-01-01	414

Form 5500 Responses for PLASKOLITE LIFE AND HEALTH INSURANCE PLAN

2022: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: PLASKOLITE LIFE AND HEALTH INSURANCE 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: PLASKOLITE LIFE AND HEALTH INSURANCE 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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
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: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: PLASKOLITE LIFE AND HEALTH INSURANCE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
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

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	26
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $9,115
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $325,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,115
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

70872

Policy instance

Insurance contract or identification number	70872
Number of Individuals Covered	847
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $52,699
Total amount of fees paid to insurance company	USD $6,663
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $584,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,699
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10346481001

Policy instance

Insurance contract or identification number	10346481001
Number of Individuals Covered	1336
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,914
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,662
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	752
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
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?	Yes

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

Policy contract number

334

Policy instance

Insurance contract or identification number	334
Number of Individuals Covered	1523
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,043
Total amount of fees paid to insurance company	USD $0
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 $8,043
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20198

Policy instance

Insurance contract or identification number	20198
Number of Individuals Covered	1004
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $17,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	66
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,935
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,840
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	30
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $9,372
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $345,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,372
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

047182A

Policy instance

Insurance contract or identification number	047182A
Number of Individuals Covered	225
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700581001

Policy instance

Insurance contract or identification number	9700581001
Number of Individuals Covered	361
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,472
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,472
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	438
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,040
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,040
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

5965235

Policy instance

Insurance contract or identification number	5965235
Number of Individuals Covered	1213
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $41,241
Total amount of fees paid to insurance company	USD $9,889
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $521,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,241
Amount paid for insurance broker fees	71
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

334

Policy instance

Insurance contract or identification number	334
Number of Individuals Covered	334
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,806
Total amount of fees paid to insurance company	USD $0
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 $12,009
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20198

Policy instance

Insurance contract or identification number	20198
Number of Individuals Covered	1004
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $17,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	921
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $542
Total amount of fees paid to insurance company	USD $46
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $542
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	66
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,005
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,404
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

047182A

Policy instance

Insurance contract or identification number	047182A
Number of Individuals Covered	261
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $18,411
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $18,411
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700581001

Policy instance

Insurance contract or identification number	9700581001
Number of Individuals Covered	417
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,327
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,923
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	880
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $542
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $542
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	456
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $408
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $408
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

5965235

Policy instance

Insurance contract or identification number	5965235
Number of Individuals Covered	1223
Insurance policy start date	2020-08-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $21,067
Total amount of fees paid to insurance company	USD $3,370
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $232,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,185
Amount paid for insurance broker fees	31
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0334

Policy instance

Insurance contract or identification number	0334
Number of Individuals Covered	1488
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,444
Total amount of fees paid to insurance company	USD $1,558
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 $11,444
Amount paid for insurance broker fees	1558
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS, RETENTION BONUS
Insurance broker organization code?	3

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20198

Policy instance

Insurance contract or identification number	20198
Number of Individuals Covered	1454
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $19,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	29
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $9,645
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,404
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	64
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,839
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,781
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	28
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $7,660
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $242,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,606
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182 ET AL

Policy instance

Insurance contract or identification number	47182 ET AL
Number of Individuals Covered	230
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $21,947
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $21,947
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700581001

Policy instance

Insurance contract or identification number	9700581001
Number of Individuals Covered	382
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,355
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,627
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	761
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $542
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $542
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	387
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,041
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,041
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

5965235

Policy instance

Insurance contract or identification number	5965235
Number of Individuals Covered	1139
Insurance policy start date	2019-08-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,409
Total amount of fees paid to insurance company	USD $649
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $226,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,409
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

334

Policy instance

Insurance contract or identification number	334
Number of Individuals Covered	1203
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $47,570
Total amount of fees paid to insurance company	USD $2,357
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
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 $47,570
Amount paid for insurance broker fees	2357
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS RETENTION BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10219391

Policy instance

Insurance contract or identification number	10219391
Number of Individuals Covered	774
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $25,312
Total amount of fees paid to insurance company	USD $2,297
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $361,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,312
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

0334

Policy instance

Insurance contract or identification number	0334
Number of Individuals Covered	1246
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,078
Total amount of fees paid to insurance company	USD $0
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 $9,078
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	65
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,679
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,477
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	32
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $9,182
Total amount of fees paid to insurance company	USD $47
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,182
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	BONUS MISCELLANEOUS COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182 ET AL

Policy instance

Insurance contract or identification number	47182 ET AL
Number of Individuals Covered	199
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $21,845
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $21,845
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	812
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $542
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $542
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700581001

Policy instance

Insurance contract or identification number	9700581001
Number of Individuals Covered	378
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,743
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,043
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	407
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,818
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,818
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10219391

Policy instance

Insurance contract or identification number	10219391
Number of Individuals Covered	710
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $16,065
Total amount of fees paid to insurance company	USD $0
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $229,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,065
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0334

Policy instance

Insurance contract or identification number	0334
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

E0208*, L7259A*

Policy instance

Insurance contract or identification number	E0208, L7259A
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-03
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47182

Policy instance

Insurance contract or identification number	47182
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10219391

Policy instance

Insurance contract or identification number	10219391
Number of Individuals Covered	540
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $14,199
Total amount of fees paid to insurance company	USD $0
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $202,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,199
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	273
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,555
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,555
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

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

Policy contract number

0334

Policy instance

Insurance contract or identification number	0334
Number of Individuals Covered	744
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,566
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $6,566
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,623
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,644
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	EMERSON REID COMPANY, INC.

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208*, L7259A*

Policy instance

Insurance contract or identification number	E0208, L7259A
Number of Individuals Covered	33
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $13,559
Total amount of fees paid to insurance company	USD $49
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $289,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,559
Amount paid for insurance broker fees	49
Additional information about fees paid to insurance broker	BONUSES AND MISCELLANEOUS COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182

Policy instance

Insurance contract or identification number	47182
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $21,794
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $21,794
Amount paid for insurance broker fees	0
Insurance broker name	THOMAS HADLEY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700581001

Policy instance

Insurance contract or identification number	9700581001
Number of Individuals Covered	193
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,146
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,146
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	604
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $542
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $542
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	583
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

GLUG0APZE

Policy instance

Insurance contract or identification number	GLUG0APZE
Number of Individuals Covered	508
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $13,395
Total amount of fees paid to insurance company	USD $7,461
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $191,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,395
Amount paid for insurance broker fees	7461
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700758

Policy instance

Insurance contract or identification number	9700758
Number of Individuals Covered	176
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $854
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $854
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	204
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,401
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

334

Policy instance

Insurance contract or identification number	334
Number of Individuals Covered	654
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,955
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $5,955
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	27
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,453
Total amount of fees paid to insurance company	USD $40
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $304,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,453
Amount paid for insurance broker fees	40
Additional information about fees paid to insurance broker	BONUS MISCELLANEOUS COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182 ET AL

Policy instance

Insurance contract or identification number	47182 ET AL
Number of Individuals Covered	208
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $17,841
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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
Commission paid to Insurance Broker	USD $17,841
Insurance broker organization code?	3
Insurance broker name	THOMAS HADLEY

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

1748

Policy instance

Insurance contract or identification number	1748
Number of Individuals Covered	74
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,404
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,056
Insurance broker organization code?	3
Insurance broker name	EMERSON REID AND COMPANY, INC.

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

Policy contract number

GLUG0APZE

Policy instance

Insurance contract or identification number	GLUG0APZE
Number of Individuals Covered	491
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $12,613
Total amount of fees paid to insurance company	USD $2,620
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $180,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,613
Amount paid for insurance broker fees	2620
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

GLUG0APZE

Policy instance

Insurance contract or identification number	GLUG0APZE
Number of Individuals Covered	494
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,609
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $94,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,609
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	516
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	184
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,323
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,323
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	31
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,349
Total amount of fees paid to insurance company	USD $46
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $310,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,349
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182/47183

Policy instance

Insurance contract or identification number	47182/47183
Number of Individuals Covered	161
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,097
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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
Commission paid to Insurance Broker	USD $14,097
Insurance broker organization code?	3
Insurance broker name	THOMAS HADLEY

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

3194

Policy instance

Insurance contract or identification number	3194
Number of Individuals Covered	35
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $971
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $971
Insurance broker organization code?	3
Insurance broker name	HIGH VIEW BENEFIT RESOURCES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700758

Policy instance

Insurance contract or identification number	9700758
Number of Individuals Covered	148
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $706
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $706
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

14430

Policy instance

Insurance contract or identification number	14430
Number of Individuals Covered	495
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,052
Total amount of fees paid to insurance company	USD $836
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $86,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,052
Insurance broker organization code?	3
Amount paid for insurance broker fees	836
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker name	WELLS FARGO INSURANCE SERVICES

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	29
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,730
Total amount of fees paid to insurance company	USD $43
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $271,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,730
Amount paid for insurance broker fees	43
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

3194

Policy instance

Insurance contract or identification number	3194
Number of Individuals Covered	29
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $740
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $740
Insurance broker organization code?	3
Insurance broker name	HIGH VIEW BENEFIT RESOURCES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700758

Policy instance

Insurance contract or identification number	9700758
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $657
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $657
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182/47183

Policy instance

Insurance contract or identification number	47182/47183
Number of Individuals Covered	140
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,968
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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
Commission paid to Insurance Broker	USD $11,968
Insurance broker organization code?	3
Insurance broker name	THOMAS HADLEY, II

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	173
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,437
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,437
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	525
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182/47183

Policy instance

Insurance contract or identification number	47182/47183
Number of Individuals Covered	93
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,429
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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
Commission paid to Insurance Broker	USD $7,429
Insurance broker organization code?	3
Insurance broker name	THOMAS HADLEY, II

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	472
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $6
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $582
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

14430

Policy instance

Insurance contract or identification number	14430
Number of Individuals Covered	457
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,690
Total amount of fees paid to insurance company	USD $1,516
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $166,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,690
Insurance broker organization code?	3
Amount paid for insurance broker fees	1516
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker name	WELLS FARGO INSURANCE SERVICES

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

3194

Policy instance

Insurance contract or identification number	3194
Number of Individuals Covered	30
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $590
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $590
Insurance broker organization code?	3
Insurance broker name	HIGH VIEW BENEFIT RESOURCES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9700758

Policy instance

Insurance contract or identification number	9700758
Number of Individuals Covered	86
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $442
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $442
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	150
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $526
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $526
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

E0208A/E0208B

Policy instance

Insurance contract or identification number	E0208A/E0208B
Number of Individuals Covered	26
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,447
Total amount of fees paid to insurance company	USD $38
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $227,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,447
Amount paid for insurance broker fees	38
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5225/CD0578

Policy instance

Insurance contract or identification number	CD5225/CD0578
Number of Individuals Covered	224
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $731
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $131,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $731
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5225/CD0578

Policy instance

Insurance contract or identification number	CD5225/CD0578
Number of Individuals Covered	207
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,454
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $114,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

47182/47183

Policy instance

Insurance contract or identification number	47182/47183
Number of Individuals Covered	98
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,208
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	138
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $514
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

14430

Policy instance

Insurance contract or identification number	14430
Number of Individuals Covered	443
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,817
Total amount of fees paid to insurance company	USD $782
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $168,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99062742

Policy instance

Insurance contract or identification number	99062742
Number of Individuals Covered	223
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-27-42

Policy instance

Insurance contract or identification number	9906-27-42
Number of Individuals Covered	464
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

14430

Policy instance

Insurance contract or identification number	14430
Number of Individuals Covered	405
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,965
Total amount of fees paid to insurance company	USD $2,376
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $170,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,965
Insurance broker organization code?	3
Amount paid for insurance broker fees	2376
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

12068348

Policy instance

Insurance contract or identification number	12068348
Number of Individuals Covered	137
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $394
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $394
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5225/CD0578

Policy instance

Insurance contract or identification number	CD5225/CD0578
Number of Individuals Covered	207
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,420
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $98,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,420
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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Company Name:	PLASKOLITE, LLC
Employer identification number (EIN):	314376110
NAIC Classification:	326100

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	1950-04-21
Company Identification Number:	217850
Legal Registered Office Address:	1770 JOYCE AVE - COLUMBUS United States of America (USA) 43216