401k Plan data: DRISCO LLC EMPLOYEE BENEFIT PLAN plan

DRISCO LLC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	DRISCO LLC EMPLOYEE BENEFIT PLAN
Plan identification number	501

DRISCO LLC EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

DRISCO, L.L.C. has sponsored the creation of one or more 401k plans.

Company Name: DRISCO, L.L.C.

Employer identification number (EIN): 331053485

NAIC Classification: 324190

Additional information about DRISCO, L.L.C.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2009-09-08

Company Identification Number: 0801168002

Legal Registered Office Address: PO BOX 149

PONCA CITY
United States of America (USA)
74602

More information about DRISCO, L.L.C.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DRISCO LLC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-10-01 SCOTT DOORNBOS 2023-05-10
501 2020-10-01
501 2020-10-01
501 2019-10-01
501 2018-10-01 TRISHA MCADOO 2020-05-15
501 2017-10-01 TRISHA MCADOO 2019-04-30
501 2016-10-01
501 2016-10-01 SCOTT DOORNBOS
501 2016-10-01 SCOTT DOORNBOS
501 2016-10-01 SCOTT DOORNBOS
501 2015-10-01 TRISHA MCADOO SCOTT DOORNBOS 2017-07-17
501 2014-10-01 TRISHA MCADOO SCOTT DOORNBOS
501 2014-10-01 TRISHA MCADOO SCOTT DOORNBOS 2016-06-21
501 2014-10-01 TRISHA MCADOO SCOTT DOORNBOS
501 2013-10-01 TRISHA MCADOO
501 2012-10-01 TRISHA MCADOO
501 2011-10-01 TRISHA MCADOO

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-10-01			SCOTT DOORNBOS	2023-05-10
501	2020-10-01
501	2020-10-01
501	2019-10-01
501	2018-10-01	TRISHA MCADOO	2020-05-15
501	2017-10-01	TRISHA MCADOO	2019-04-30
501	2016-10-01
501	2016-10-01			SCOTT DOORNBOS
501	2016-10-01			SCOTT DOORNBOS
501	2016-10-01			SCOTT DOORNBOS
501	2015-10-01	TRISHA MCADOO		SCOTT DOORNBOS	2017-07-17
501	2014-10-01	TRISHA MCADOO		SCOTT DOORNBOS
501	2014-10-01	TRISHA MCADOO		SCOTT DOORNBOS	2016-06-21
501	2014-10-01	TRISHA MCADOO		SCOTT DOORNBOS
501	2013-10-01	TRISHA MCADOO
501	2012-10-01	TRISHA MCADOO
501	2011-10-01	TRISHA MCADOO

Plan Statistics for DRISCO LLC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for DRISCO LLC EMPLOYEE BENEFIT PLAN

Measure Date Value
2021: DRISCO LLC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 127
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 96
Number of retired or separated participants receiving benefits 2021-10-01 0
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 96
2020: DRISCO LLC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 123
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 0
Number of retired or separated participants receiving benefits 2020-10-01 0
Number of other retired or separated participants entitled to future benefits 2020-10-01 0
Total of all active and inactive participants 2020-10-01 0
2019: DRISCO LLC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 124
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 123
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 123
2018: DRISCO LLC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-10-01 118
Total number of active participants reported on line 7a of the Form 5500 2018-10-01 124
Number of retired or separated participants receiving benefits 2018-10-01 0
Number of other retired or separated participants entitled to future benefits 2018-10-01 0
Total of all active and inactive participants 2018-10-01 124
2017: DRISCO LLC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-10-01 135
Total number of active participants reported on line 7a of the Form 5500 2017-10-01 118
Number of retired or separated participants receiving benefits 2017-10-01 0
Number of other retired or separated participants entitled to future benefits 2017-10-01 0
Total of all active and inactive participants 2017-10-01 118
2016: DRISCO LLC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-10-01 120
Total number of active participants reported on line 7a of the Form 5500 2016-10-01 135
Number of retired or separated participants receiving benefits 2016-10-01 0
Number of other retired or separated participants entitled to future benefits 2016-10-01 0
Total of all active and inactive participants 2016-10-01 135
2015: DRISCO LLC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-10-01 120
Total number of active participants reported on line 7a of the Form 5500 2015-10-01 120
Number of retired or separated participants receiving benefits 2015-10-01 0
Number of other retired or separated participants entitled to future benefits 2015-10-01 0
Total of all active and inactive participants 2015-10-01 120
2014: DRISCO LLC EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-10-01 91
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 120
Number of retired or separated participants receiving benefits 2014-10-01 0
Number of other retired or separated participants entitled to future benefits 2014-10-01 0
Total of all active and inactive participants 2014-10-01 120
2013: DRISCO LLC EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-10-01 131
Total number of active participants reported on line 7a of the Form 5500 2013-10-01 91
Total of all active and inactive participants 2013-10-01 91
2012: DRISCO LLC EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-10-01 125
Total number of active participants reported on line 7a of the Form 5500 2012-10-01 131
Total of all active and inactive participants 2012-10-01 131
2011: DRISCO LLC EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-10-01 119
Total number of active participants reported on line 7a of the Form 5500 2011-10-01 125
Total of all active and inactive participants 2011-10-01 125

Measure	Date	Value
2021: DRISCO LLC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	127
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	96
Number of retired or separated participants receiving benefits	2021-10-01	0
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	96
2020: DRISCO LLC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	123
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	0
Number of retired or separated participants receiving benefits	2020-10-01	0
Number of other retired or separated participants entitled to future benefits	2020-10-01	0
Total of all active and inactive participants	2020-10-01	0
2019: DRISCO LLC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	124
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	123
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	123
2018: DRISCO LLC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-10-01	118
Total number of active participants reported on line 7a of the Form 5500	2018-10-01	124
Number of retired or separated participants receiving benefits	2018-10-01	0
Number of other retired or separated participants entitled to future benefits	2018-10-01	0
Total of all active and inactive participants	2018-10-01	124
2017: DRISCO LLC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-10-01	135
Total number of active participants reported on line 7a of the Form 5500	2017-10-01	118
Number of retired or separated participants receiving benefits	2017-10-01	0
Number of other retired or separated participants entitled to future benefits	2017-10-01	0
Total of all active and inactive participants	2017-10-01	118
2016: DRISCO LLC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-10-01	120
Total number of active participants reported on line 7a of the Form 5500	2016-10-01	135
Number of retired or separated participants receiving benefits	2016-10-01	0
Number of other retired or separated participants entitled to future benefits	2016-10-01	0
Total of all active and inactive participants	2016-10-01	135
2015: DRISCO LLC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-10-01	120
Total number of active participants reported on line 7a of the Form 5500	2015-10-01	120
Number of retired or separated participants receiving benefits	2015-10-01	0
Number of other retired or separated participants entitled to future benefits	2015-10-01	0
Total of all active and inactive participants	2015-10-01	120
2014: DRISCO LLC EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-10-01	91
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	120
Number of retired or separated participants receiving benefits	2014-10-01	0
Number of other retired or separated participants entitled to future benefits	2014-10-01	0
Total of all active and inactive participants	2014-10-01	120
2013: DRISCO LLC EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-10-01	131
Total number of active participants reported on line 7a of the Form 5500	2013-10-01	91
Total of all active and inactive participants	2013-10-01	91
2012: DRISCO LLC EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-10-01	125
Total number of active participants reported on line 7a of the Form 5500	2012-10-01	131
Total of all active and inactive participants	2012-10-01	131
2011: DRISCO LLC EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-10-01	119
Total number of active participants reported on line 7a of the Form 5500	2011-10-01	125
Total of all active and inactive participants	2011-10-01	125

Form 5500 Responses for DRISCO LLC EMPLOYEE BENEFIT PLAN

2021: DRISCO LLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: DRISCO LLC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	Submission has been amended	Yes
2020-10-01	This submission is the final filing	Yes
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: DRISCO LLC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: DRISCO LLC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-10-01	Type of plan entity	Single employer plan
2018-10-01	Plan funding arrangement – Insurance	Yes
2018-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-10-01	Plan benefit arrangement – Insurance	Yes
2018-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: DRISCO LLC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-10-01	Type of plan entity	Single employer plan
2017-10-01	Plan funding arrangement – Insurance	Yes
2017-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-10-01	Plan benefit arrangement – Insurance	Yes
2017-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: DRISCO LLC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-10-01	Type of plan entity	Single employer plan
2016-10-01	Submission has been amended	Yes
2016-10-01	Plan funding arrangement – Insurance	Yes
2016-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-10-01	Plan benefit arrangement – Insurance	Yes
2016-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: DRISCO LLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-10-01	Type of plan entity	Single employer plan
2015-10-01	Plan funding arrangement – Insurance	Yes
2015-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-10-01	Plan benefit arrangement – Insurance	Yes
2015-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: DRISCO LLC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Submission has been amended	Yes
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: DRISCO LLC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-10-01	Type of plan entity	Single employer plan
2013-10-01	Plan funding arrangement – Insurance	Yes
2013-10-01	Plan benefit arrangement – Insurance	Yes
2012: DRISCO LLC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Plan funding arrangement – Insurance	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: DRISCO LLC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	First time form 5500 has been submitted	Yes
2011-10-01	Plan funding arrangement – Insurance	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	5
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $618
Total amount of fees paid to insurance company	USD $43
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $3,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $164
Insurance broker organization code?	3
Amount paid for insurance broker fees	31

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

956785806

Policy instance

Insurance contract or identification number	956785806
Number of Individuals Covered	121
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $32,707
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $891,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,707
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00003

Policy instance

Insurance contract or identification number	51597-000-00003
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00001

Policy instance

Insurance contract or identification number	51597-000-00001
Number of Individuals Covered	61
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $427
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $427
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	116
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $8,751
Total amount of fees paid to insurance company	USD $1,473
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $72,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,719
Amount paid for insurance broker fees	1473
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	12
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $867
Total amount of fees paid to insurance company	USD $13
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $239
Insurance broker organization code?	3
Amount paid for insurance broker fees	11

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	10
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $1,525
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $725
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	12
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $1,017
Total amount of fees paid to insurance company	USD $17
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $425
Amount paid for insurance broker fees	14
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	127
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $8,765
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $74,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,792
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00001

Policy instance

Insurance contract or identification number	51597-000-00001
Number of Individuals Covered	65
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $458
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $458
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

956785806

Policy instance

Insurance contract or identification number	956785806
Number of Individuals Covered	121
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $35,977
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,977
Insurance broker organization code?	3

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

Policy contract number

417002414125

Policy instance

Insurance contract or identification number	417002414125
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00003

Policy instance

Insurance contract or identification number	51597-000-00003
Number of Individuals Covered	1
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	11
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	12
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	123
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00001

Policy instance

Insurance contract or identification number	51597-000-00001
Number of Individuals Covered	56
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Dental Insurance Welfare Benefit	Yes
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

417002414125

Policy instance

Insurance contract or identification number	417002414125
Number of Individuals Covered	90
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Welfare Benefit Premiums Paid to Carrier	USD $214,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	11
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $304
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $1,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $159
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00003

Policy instance

Insurance contract or identification number	51597-000-00003
Number of Individuals Covered	1
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	12
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $499
Total amount of fees paid to insurance company	USD $20
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $226
Amount paid for insurance broker fees	14
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	123
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $9,071
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $77,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,071
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597-000-00001

Policy instance

Insurance contract or identification number	51597-000-00001
Number of Individuals Covered	56
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $428
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $428
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	124
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $7,101
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $58,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,101
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	7
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $837
Total amount of fees paid to insurance company	USD $14
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $421
Amount paid for insurance broker fees	12
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	6
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $429
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $196
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597

Policy instance

Insurance contract or identification number	51597
Number of Individuals Covered	56
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $1,898
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,898
Insurance broker organization code?	3

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

Policy contract number

HCL32587

Policy instance

Insurance contract or identification number	HCL32587
Number of Individuals Covered	89
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Welfare Benefit Premiums Paid to Carrier	USD $205,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

882255G

Policy instance

Insurance contract or identification number	882255G
Number of Individuals Covered	118
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $8,000
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $67,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

HA726

Policy instance

Insurance contract or identification number	HA726
Number of Individuals Covered	7
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $938
Total amount of fees paid to insurance company	USD $24
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

SG029

Policy instance

Insurance contract or identification number	SG029
Number of Individuals Covered	6
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $401
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $3,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597

Policy instance

Insurance contract or identification number	51597
Number of Individuals Covered	53
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $401
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,198
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

HCL32587

Policy instance

Insurance contract or identification number	HCL32587
Number of Individuals Covered	87
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $520
Welfare Benefit Premiums Paid to Carrier	USD $189,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1000685

Policy instance

Insurance contract or identification number	1000685
Number of Individuals Covered	92
Insurance policy start date	2014-11-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $797
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $7,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $797
Insurance broker organization code?	3
Insurance broker name	CAPROCK HEALTHPLANS

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

Policy contract number

232079

Policy instance

Insurance contract or identification number	232079
Number of Individuals Covered	120
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $2,369
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $208
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST LLC

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597

Policy instance

Insurance contract or identification number	51597
Number of Individuals Covered	55
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $1,934
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,934
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

NUTA-1360

Policy instance

Insurance contract or identification number	NUTA-1360
Number of Individuals Covered	92
Insurance policy start date	2014-11-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $53,403
Welfare Benefit Premiums Paid to Carrier	USD $117,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,891
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

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

Policy contract number

232079

Policy instance

Insurance contract or identification number	232079
Number of Individuals Covered	33
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $3,184
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $264
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST LLC

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

Policy contract number

0752665

Policy instance

Insurance contract or identification number	0752665
Number of Individuals Covered	47
Insurance policy start date	2014-10-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $3,517
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,517
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS, INC.

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

Policy contract number

752665

Policy instance

Insurance contract or identification number	752665
Number of Individuals Covered	211
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $35,977
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $960,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,977
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS, INC

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597

Policy instance

Insurance contract or identification number	51597
Number of Individuals Covered	65
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $563
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $563
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

232079

Policy instance

Insurance contract or identification number	232079
Number of Individuals Covered	126
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $2,525
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,525
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS, INC

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

Policy contract number

232079

Policy instance

Insurance contract or identification number	232079
Number of Individuals Covered	44
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $4,391
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,391
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 204678

Policy instance

Insurance contract or identification number	VAR 204678
Number of Individuals Covered	23
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $467
Total amount of fees paid to insurance company	USD $30
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $467
Amount paid for insurance broker fees	30
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181797

Policy instance

Insurance contract or identification number	VG 181797
Number of Individuals Covered	39
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,601
Total amount of fees paid to insurance company	USD $147
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 $16,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,601
Amount paid for insurance broker fees	147
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS INC

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51597

Policy instance

Insurance contract or identification number	51597
Number of Individuals Covered	81
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $642
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $642
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS INC

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

Policy contract number

752665

Policy instance

Insurance contract or identification number	752665
Number of Individuals Covered	259
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $8,817
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $876,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,817
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 146237

Policy instance

Insurance contract or identification number	GL 146237
Number of Individuals Covered	131
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,122
Total amount of fees paid to insurance company	USD $95
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Amount paid for insurance broker fees	95
Insurance broker organization code?	3
Insurance broker name	WILLIS OF GREATER KANSAS INC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

330020

Policy instance

Insurance contract or identification number	330020
Number of Individuals Covered	3
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $1,159
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )

Policy contract number

580755

Policy instance

Insurance contract or identification number	580755
Number of Individuals Covered	31
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $10,168
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 146237

Policy instance

Insurance contract or identification number	GL 146237
Number of Individuals Covered	125
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $952
Total amount of fees paid to insurance company	USD $48
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

720165

Policy instance

Insurance contract or identification number	720165
Number of Individuals Covered	4
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $1,248
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

780966

Policy instance

Insurance contract or identification number	780966
Number of Individuals Covered	1
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $4,290
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

780434

Policy instance

Insurance contract or identification number	780434
Number of Individuals Covered	23
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $5,821
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

780964

Policy instance

Insurance contract or identification number	780964
Number of Individuals Covered	1
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $68
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )

Policy contract number

580757

Policy instance

Insurance contract or identification number	580757
Number of Individuals Covered	15
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $10,168
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	DRISCO, L.L.C.
Employer identification number (EIN):	331053485
NAIC Classification:	324190

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2009-09-08
Company Identification Number:	0801168002
Legal Registered Office Address:	PO BOX 149 PONCA CITY United States of America (USA) 74602