401k Plan data: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN plan

21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 401k Plan overview

Plan Name	21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN
Plan identification number	501

21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

21ST CENTURY EQUIPMENT, LLC has sponsored the creation of one or more 401k plans.

Company Name: 21ST CENTURY EQUIPMENT, LLC

Employer identification number (EIN): 320218771

NAIC Classification: 423800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-04-01
501 2021-04-01
501 2020-04-01
501 2019-04-01
501 2018-04-01
501 2017-04-01 PATTY WOODMANCY
501 2016-04-01 PATTY WOODMANCY
501 2015-04-01 PATTY WOODMANCY
501 2014-04-01 PATTY WOODMANCY
501 2013-04-01 PATTY WOODMANCY
501 2012-04-01 PATTY WOODMANCY
501 2011-04-01 PATTY WOODMANCY
501 2009-04-01 PATTY WOODMANCY PATTY WOODMANCY 2010-06-24

Plan Statistics for 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN

401k plan membership statisitcs for 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN

Measure Date Value
2022: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year 2022-04-01 265
Total number of active participants reported on line 7a of the Form 5500 2022-04-01 292
Number of retired or separated participants receiving benefits 2022-04-01 3
Number of other retired or separated participants entitled to future benefits 2022-04-01 0
Total of all active and inactive participants 2022-04-01 295
2021: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year 2021-04-01 234
Total number of active participants reported on line 7a of the Form 5500 2021-04-01 254
Number of retired or separated participants receiving benefits 2021-04-01 4
Total of all active and inactive participants 2021-04-01 258
2020: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year 2020-04-01 253
Total number of active participants reported on line 7a of the Form 5500 2020-04-01 243
Number of retired or separated participants receiving benefits 2020-04-01 3
Number of other retired or separated participants entitled to future benefits 2020-04-01 0
Total of all active and inactive participants 2020-04-01 246
2019: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-04-01 253
Total number of active participants reported on line 7a of the Form 5500 2019-04-01 253
Number of retired or separated participants receiving benefits 2019-04-01 2
Number of other retired or separated participants entitled to future benefits 2019-04-01 0
Total of all active and inactive participants 2019-04-01 255
2018: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 238
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 253
Number of retired or separated participants receiving benefits 2018-04-01 2
Number of other retired or separated participants entitled to future benefits 2018-04-01 0
Total of all active and inactive participants 2018-04-01 255
2017: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year 2017-04-01 251
Total number of active participants reported on line 7a of the Form 5500 2017-04-01 232
Number of retired or separated participants receiving benefits 2017-04-01 0
Number of other retired or separated participants entitled to future benefits 2017-04-01 0
Total of all active and inactive participants 2017-04-01 232
2016: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-04-01 264
Total number of active participants reported on line 7a of the Form 5500 2016-04-01 250
Number of retired or separated participants receiving benefits 2016-04-01 2
Number of other retired or separated participants entitled to future benefits 2016-04-01 0
Total of all active and inactive participants 2016-04-01 252
2015: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 267
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 260
Number of retired or separated participants receiving benefits 2015-04-01 0
Number of other retired or separated participants entitled to future benefits 2015-04-01 0
Total of all active and inactive participants 2015-04-01 260
2014: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 270
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 274
Number of retired or separated participants receiving benefits 2014-04-01 0
Number of other retired or separated participants entitled to future benefits 2014-04-01 0
Total of all active and inactive participants 2014-04-01 274
2013: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 195
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 290
Number of retired or separated participants receiving benefits 2013-04-01 0
Total of all active and inactive participants 2013-04-01 290
2012: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 203
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 197
Number of retired or separated participants receiving benefits 2012-04-01 6
Total of all active and inactive participants 2012-04-01 203
2011: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year 2011-04-01 116
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 205
Total of all active and inactive participants 2011-04-01 205
2009: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year 2009-04-01 143
Total number of active participants reported on line 7a of the Form 5500 2009-04-01 163
Number of retired or separated participants receiving benefits 2009-04-01 0
Number of other retired or separated participants entitled to future benefits 2009-04-01 0
Total of all active and inactive participants 2009-04-01 163

Measure	Date	Value
2022: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year	2022-04-01	265
Total number of active participants reported on line 7a of the Form 5500	2022-04-01	292
Number of retired or separated participants receiving benefits	2022-04-01	3
Number of other retired or separated participants entitled to future benefits	2022-04-01	0
Total of all active and inactive participants	2022-04-01	295
2021: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year	2021-04-01	234
Total number of active participants reported on line 7a of the Form 5500	2021-04-01	254
Number of retired or separated participants receiving benefits	2021-04-01	4
Total of all active and inactive participants	2021-04-01	258
2020: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	253
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	243
Number of retired or separated participants receiving benefits	2020-04-01	3
Number of other retired or separated participants entitled to future benefits	2020-04-01	0
Total of all active and inactive participants	2020-04-01	246
2019: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	253
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	253
Number of retired or separated participants receiving benefits	2019-04-01	2
Number of other retired or separated participants entitled to future benefits	2019-04-01	0
Total of all active and inactive participants	2019-04-01	255
2018: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	238
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	253
Number of retired or separated participants receiving benefits	2018-04-01	2
Number of other retired or separated participants entitled to future benefits	2018-04-01	0
Total of all active and inactive participants	2018-04-01	255
2017: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	251
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	232
Number of retired or separated participants receiving benefits	2017-04-01	0
Number of other retired or separated participants entitled to future benefits	2017-04-01	0
Total of all active and inactive participants	2017-04-01	232
2016: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	264
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	250
Number of retired or separated participants receiving benefits	2016-04-01	2
Number of other retired or separated participants entitled to future benefits	2016-04-01	0
Total of all active and inactive participants	2016-04-01	252
2015: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	267
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	260
Number of retired or separated participants receiving benefits	2015-04-01	0
Number of other retired or separated participants entitled to future benefits	2015-04-01	0
Total of all active and inactive participants	2015-04-01	260
2014: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	270
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	274
Number of retired or separated participants receiving benefits	2014-04-01	0
Number of other retired or separated participants entitled to future benefits	2014-04-01	0
Total of all active and inactive participants	2014-04-01	274
2013: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	195
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	290
Number of retired or separated participants receiving benefits	2013-04-01	0
Total of all active and inactive participants	2013-04-01	290
2012: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	203
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	197
Number of retired or separated participants receiving benefits	2012-04-01	6
Total of all active and inactive participants	2012-04-01	203
2011: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	116
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	205
Total of all active and inactive participants	2011-04-01	205
2009: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year	2009-04-01	143
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	163
Number of retired or separated participants receiving benefits	2009-04-01	0
Number of other retired or separated participants entitled to future benefits	2009-04-01	0
Total of all active and inactive participants	2009-04-01	163

Form 5500 Responses for 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN

2022: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2022 form 5500 responses
2022-04-01	Type of plan entity	Single employer plan
2022-04-01	Plan funding arrangement – Insurance	Yes
2022-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-04-01	Plan benefit arrangement – Insurance	Yes
2022-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2021 form 5500 responses
2021-04-01	Type of plan entity	Single employer plan
2021-04-01	Plan funding arrangement – Insurance	Yes
2021-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-04-01	Plan benefit arrangement – Insurance	Yes
2021-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
2020-04-01	Plan funding arrangement – Insurance	Yes
2020-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-04-01	Plan benefit arrangement – Insurance	Yes
2020-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes
2018-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2009: 21ST CENTURY EQUIPMENT, LLC EMPLOYEE MEDICAL PLAN 2009 form 5500 responses
2009-04-01	Type of plan entity	Single employer plan
2009-04-01	This submission is the final filing	No
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	236
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $13,047
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $70,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,047
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	305
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $800
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $800
Insurance broker organization code?	3

GRANULAR INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93521 )

Policy contract number

2022-220-NE

Policy instance

Insurance contract or identification number	2022-220-NE
Number of Individuals Covered	294
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $28,949
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $964,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,949
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	139
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,525
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	403
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $13,141
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	403
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,278
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	77
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $6,021
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	51
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,291
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	68
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $599
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	33
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT40588

Policy instance

Insurance contract or identification number	HCCLOT40588
Number of Individuals Covered	291
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $6,939
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $69,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,939
Insurance broker organization code?	7

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

Policy contract number

E4915617

Policy instance

Insurance contract or identification number	E4915617
Number of Individuals Covered	175
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $41,488
Total amount of fees paid to insurance company	USD $933
Other welfare benefits provided	VOLUNTARY/SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $224,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,269
Insurance broker organization code?	3
Amount paid for insurance broker fees	933

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	21
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PERSONAL ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $38
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	68
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	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $7,950
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	379
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	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,577
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	379
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	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $16,053
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	101
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	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	255
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $752
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $752
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	52
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	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $518
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	49
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	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,490
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	219
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $15,678
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $85,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,678
Insurance broker organization code?	3

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

Policy contract number

E4915617

Policy instance

Insurance contract or identification number	E4915617
Number of Individuals Covered	155
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,405
Total amount of fees paid to insurance company	USD $229
Other welfare benefits provided	VOLUNTARY/SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $203,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,693
Insurance broker organization code?	3
Amount paid for insurance broker fees	229
Additional information about fees paid to insurance broker	ADMIN FEES

SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 38776 )

Policy contract number

SG1033-2021

Policy instance

Insurance contract or identification number	SG1033-2021
Number of Individuals Covered	114
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
Welfare Benefit Premiums Paid to Carrier	USD $689,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT40588

Policy instance

Insurance contract or identification number	HCCLOT40588
Number of Individuals Covered	261
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $5,161
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $51,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,161
Insurance broker organization code?	7

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	34
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,536
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	33
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,458
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	88
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,547
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	205
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $15,117
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $80,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,117
Insurance broker organization code?	3

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

Policy contract number

E4905617

Policy instance

Insurance contract or identification number	E4905617
Number of Individuals Covered	176
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $40,762
Total amount of fees paid to insurance company	USD $531
Other welfare benefits provided	VOLUNTARY/SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $225,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,079
Insurance broker organization code?	3
Amount paid for insurance broker fees	531

SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 38776 )

Policy contract number

SG1018-2020

Policy instance

Insurance contract or identification number	SG1018-2020
Number of Individuals Covered	108
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $601,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT40588

Policy instance

Insurance contract or identification number	HCCLOT40588
Number of Individuals Covered	238
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $5,167
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $51,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,716
Insurance broker organization code?	7

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	353
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $15,591
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	42
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,432
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	57
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $7,917
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	353
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,742
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	37
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	243
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $811
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $811
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	202
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $13,692
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $73,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,692
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	57
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $6,514
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	44
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,535
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	41
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $466
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	31
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,704
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	342
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT40588

Policy instance

Insurance contract or identification number	HCCLOT40588
Number of Individuals Covered	253
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $5,559
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $55,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,559
Insurance broker organization code?	3

STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 63657 )

Policy contract number

UMEGSL000020

Policy instance

Insurance contract or identification number	UMEGSL000020
Number of Individuals Covered	576
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $17,148
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $571,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,148
Insurance broker organization code?	3

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

Policy contract number

E4905617

Policy instance

Insurance contract or identification number	E4905617
Number of Individuals Covered	173
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $54,780
Total amount of fees paid to insurance company	USD $542
Other welfare benefits provided	VOLUNTARY/SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $209,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,026
Insurance broker organization code?	3
Amount paid for insurance broker fees	407

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	246
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $750
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $750
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	342
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $14,828
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	82
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,845
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	65
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,788
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	324
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $14,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	29
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $712
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $712
Insurance broker organization code?	3

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

US952509

Policy instance

Insurance contract or identification number	US952509
Number of Individuals Covered	232
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	28
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

947-5138

Policy instance

Insurance contract or identification number	947-5138
Number of Individuals Covered	253
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $5,890
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $58,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,890
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	39
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $434
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	186
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $12,018
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $63,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,018
Insurance broker organization code?	3

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	48
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,626
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	55
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $5,857
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	324
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	217
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $8,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CL160423

Policy instance

Insurance contract or identification number	CL160423
Number of Individuals Covered	227
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	226
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $613
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $613
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	175
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $55,659
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	313
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,461
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	175
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	313
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $16,030
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	313
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,432
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $5,042
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,895
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

947-5138

Policy instance

Insurance contract or identification number	947-5138
Number of Individuals Covered	233
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $5,799
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $57,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,799
Insurance broker organization code?	3
Insurance broker name	REGIONAL CARE, INC.

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	26
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $11,280
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,280
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION - FOR ALL PRUDENTIAL POLICIES.
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	63
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	253
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $762
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $762
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	177
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $10,282
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $63,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,282
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )

Policy contract number

ANTX-44147

Policy instance

Insurance contract or identification number	ANTX-44147
Number of Individuals Covered	262
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $347,378
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	177
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $46,427
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	56
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,521
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	3
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $14
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	377
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,298
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	377
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $19,259
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	377
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,039
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $4,427
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $2,119
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

947-1145

Policy instance

Insurance contract or identification number	947-1145
Number of Individuals Covered	262
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $6,379
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $63,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,379
Insurance broker organization code?	3
Insurance broker name	REGIONAL CARE, INC.

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	32
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,731
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	391
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,242
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	10
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $326
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	157
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $39,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )

Policy contract number

ANTX-44147

Policy instance

Insurance contract or identification number	ANTX-44147
Number of Individuals Covered	274
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $355,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	244
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $805
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $805
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	37
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,949
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	391
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $18,156
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	391
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,086
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $3,751
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $2,288
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-7799

Policy instance

Insurance contract or identification number	949-7799
Number of Individuals Covered	265
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $5,527
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $55,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,527
Insurance broker organization code?	3
Insurance broker name	REGIONAL CARE, INC.

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	157
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $8,408
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $47,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,408
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	119
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $29,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )

Policy contract number

ANTX-44147

Policy instance

Insurance contract or identification number	ANTX-44147
Number of Individuals Covered	195
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $275,824
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	119
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $24,404
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	36
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $764
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	12
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $231
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	359
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,304
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	359
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $10,236
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $2,187
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,709
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $153
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	359
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $5,039
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,039
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	186
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $652
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $652
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	197
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $705
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $705
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

AFASLP201101256

Policy instance

Insurance contract or identification number	AFASLP201101256
Number of Individuals Covered	196
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $281,893
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	90
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $21,410
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	14
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $506
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	4
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $150
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	280
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $4,257
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,257
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	280
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,778
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,575
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,540
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $118
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	90
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $25,298
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	280
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $8,396
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	85
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $23,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

AFASLP201101256

Policy instance

Insurance contract or identification number	AFASLP201101256
Number of Individuals Covered	201
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $163,928
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	85
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $19,849
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	15
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $413
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	3
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $212
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	271
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,963
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,505
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $89
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	271
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,857
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	271
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,648
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,332
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	0
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	134
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $513
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	4
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12220995

Policy instance

Insurance contract or identification number	12220995
Number of Individuals Covered	136
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $490
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $490
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35408 )

Policy contract number

001199

Policy instance

Insurance contract or identification number	001199
Number of Individuals Covered	102
Insurance policy start date	2010-04-01
Insurance policy end date	2011-04-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $136,856
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	40
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,304
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	12
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $390
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	164
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,836
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	164
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $2,723
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,723
Insurance broker organization code?	3
Insurance broker name	STEVEN R. JOBMAN, INC

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

Policy contract number

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	164
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,037
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,286
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BASIC DEP LIFE SPOUSE/FAMILY
Welfare Benefit Premiums Paid to Carrier	USD $1,529
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

08038

Policy instance

Insurance contract or identification number	08038
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $76
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

08038

Policy instance

Insurance contract or identification number	08038
Number of Individuals Covered	40
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $14,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	21ST CENTURY EQUIPMENT, LLC
Employer identification number (EIN):	320218771
NAIC Classification:	423800