401k Plan data: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN plan

MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN
Plan identification number	501

MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN Benefits

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

401k Sponsoring company profile

MARKETPLACE HOLDINGS INC AND SUBS F/K/A COLLIS FOODS INC has sponsored the creation of one or more 401k plans.

Company Name: MARKETPLACE HOLDINGS INC AND SUBS F/K/A COLLIS FOODS INC

Employer identification number (EIN): 331072677

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 GENE PETWAY
501 2015-01-01 GENE PETWAY
501 2014-01-01 GENE PETWAY
501 2013-01-01 GENE PETWAY
501 2012-01-01 GENE PETWAY
501 2011-01-01 GENE PETWAY

Plan id#	Filing Submission Date	Name of Administrator
501	2016-01-01	GENE PETWAY
501	2015-01-01	GENE PETWAY
501	2014-01-01	GENE PETWAY
501	2013-01-01	GENE PETWAY
501	2012-01-01	GENE PETWAY
501	2011-01-01	GENE PETWAY

Plan Statistics for MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN

401k plan membership statisitcs for MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN

Measure Date Value
2016: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 190
Total of all active and inactive participants 2013-01-01 0
2012: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 184
Total of all active and inactive participants 2012-01-01 0
2011: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 203
Total of all active and inactive participants 2011-01-01 0

Measure	Date	Value
2016: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	190
Total of all active and inactive participants	2013-01-01	0
2012: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	184
Total of all active and inactive participants	2012-01-01	0
2011: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	203
Total of all active and inactive participants	2011-01-01	0

Form 5500 Responses for MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN

2016: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	This submission is the final filing	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MARKETPLACE HOLDINGS HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	188
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $6,305
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $57,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,305
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	61
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $1,083
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,083
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	73
Insurance policy start date	2014-03-06
Insurance policy end date	2015-03-04
Total amount of commissions paid to insurance broker	USD $2,495
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,495
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	49
Insurance policy start date	2014-03-06
Insurance policy end date	2015-03-04
Total amount of commissions paid to insurance broker	USD $488
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $488
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	26
Insurance policy start date	2014-03-06
Insurance policy end date	2015-03-04
Total amount of commissions paid to insurance broker	USD $553
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $553
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	86
Insurance policy start date	2014-03-06
Insurance policy end date	2015-03-04
Total amount of commissions paid to insurance broker	USD $7,012
Welfare Benefit Premiums Paid to Carrier	USD $140,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,012
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	83
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of fees paid to insurance company	USD $25,652
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $855,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	25652
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	69
Insurance policy start date	2013-03-07
Insurance policy end date	2014-03-05
Total amount of commissions paid to insurance broker	USD $7,206
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $144,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,206
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	24
Insurance policy start date	2013-03-07
Insurance policy end date	2014-03-05
Total amount of commissions paid to insurance broker	USD $709
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $709
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	36
Insurance policy start date	2013-03-07
Insurance policy end date	2014-03-05
Total amount of commissions paid to insurance broker	USD $548
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $548
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	61
Insurance policy start date	2013-03-07
Insurance policy end date	2014-03-05
Total amount of commissions paid to insurance broker	USD $2,370
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,370
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	159
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $933
Total amount of fees paid to insurance company	USD $25,358
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $851,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Amount paid for insurance broker fees	25358
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	167
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,137
Total amount of fees paid to insurance company	USD $1,055
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $51,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,137
Amount paid for insurance broker fees	1055
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	70
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,559
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,559
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	36
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $735
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $735
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	60
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,527
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,527
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	159
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $975
Total amount of fees paid to insurance company	USD $16,276
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $563,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $975
Amount paid for insurance broker fees	16276
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	190
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $6,622
Total amount of fees paid to insurance company	USD $1,113
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $66,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,622
Amount paid for insurance broker fees	1113
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	53
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $561
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $561
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	184
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $6,359
Total amount of fees paid to insurance company	USD $612
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $63,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,359
Amount paid for insurance broker fees	612
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	159
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $21,822
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $676,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,822
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	92
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,834
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,834
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	72
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $613
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,135
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
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	47
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $851
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $851
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	108
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,025
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,025
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	46
Insurance policy start date	2010-11-04
Insurance policy end date	2011-11-03
Total amount of commissions paid to insurance broker	USD $888
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,883
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

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	79
Insurance policy start date	2010-11-04
Insurance policy end date	2011-11-03
Total amount of commissions paid to insurance broker	USD $631
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,311
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

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	77
Insurance policy start date	2010-11-04
Insurance policy end date	2011-11-03
Total amount of commissions paid to insurance broker	USD $2,602
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,020
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

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	163
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $23,517
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $723,579
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

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	203
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $6,018
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $60,034
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

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	102
Insurance policy start date	2010-11-04
Insurance policy end date	2011-11-03
Total amount of commissions paid to insurance broker	USD $7,227
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $144,537
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

BCM000911

Policy instance

Insurance contract or identification number	BCM000911
Number of Individuals Covered	79
Insurance policy start date	2009-11-05
Insurance policy end date	2010-09-08
Total amount of commissions paid to insurance broker	USD $5,723
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,723
Insurance broker organization code?	4
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCS000513

Policy instance

Insurance contract or identification number	BCS000513
Number of Individuals Covered	36
Insurance policy start date	2009-11-05
Insurance policy end date	2010-09-08
Total amount of commissions paid to insurance broker	USD $741
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $741
Insurance broker organization code?	4
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCD000512

Policy instance

Insurance contract or identification number	BCD000512
Number of Individuals Covered	68
Insurance policy start date	2009-11-05
Insurance policy end date	2010-09-08
Total amount of commissions paid to insurance broker	USD $2,174
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,174
Insurance broker organization code?	4
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

0705414

Policy instance

Insurance contract or identification number	0705414
Number of Individuals Covered	163
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $21,340
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $771,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,340
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

044643G

Policy instance

Insurance contract or identification number	044643G
Number of Individuals Covered	218
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $5,460
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATHDISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $49,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,460
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

BCL000513

Policy instance

Insurance contract or identification number	BCL000513
Number of Individuals Covered	58
Insurance policy start date	2009-11-05
Insurance policy end date	2010-09-08
Total amount of commissions paid to insurance broker	USD $507
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $507
Insurance broker organization code?	4
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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Company Name:	MARKETPLACE HOLDINGS INC AND SUBS F/K/A COLLIS FOODS INC
Employer identification number (EIN):	331072677
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants