401k Plan data: MILLER POULTRY EMPLOYEE BENEFIT PLAN plan

MILLER POULTRY EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	MILLER POULTRY EMPLOYEE BENEFIT PLAN
Plan identification number	501

MILLER POULTRY EMPLOYEE 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) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

MILLER POULTRY EMPLOYEE BENEFIT PLAN has sponsored the creation of one or more 401k plans.

Company Name: MILLER POULTRY EMPLOYEE BENEFIT PLAN

Employer identification number (EIN): 350175710

NAIC Classification: 315220
NAIC Description: Men's and Boys' Cut and Sew Apparel Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MILLER POULTRY EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 STUART BLACKBURN 2023-03-09
501 2021-01-01 STUART BLACKBURN 2022-09-16
501 2020-01-01 KAREN BRENNEMAN 2021-05-07
501 2019-01-01 KAREN BRENNEMAN 2020-10-06
501 2018-01-01
501 2017-01-01
501 2016-01-01 KAREN BRENNEMAN 2018-10-15
501 2015-01-01 KAREN BRENNEMAN 2018-10-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	STUART BLACKBURN	2023-03-09
501	2021-01-01	STUART BLACKBURN	2022-09-16
501	2020-01-01	KAREN BRENNEMAN	2021-05-07
501	2019-01-01	KAREN BRENNEMAN	2020-10-06
501	2018-01-01
501	2017-01-01
501	2016-01-01	KAREN BRENNEMAN	2018-10-15
501	2015-01-01	KAREN BRENNEMAN	2018-10-15

Plan Statistics for MILLER POULTRY EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for MILLER POULTRY EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 524
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 533
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 1
Total of all active and inactive participants 2022-01-01 534
2021: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 580
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 524
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 2
Total of all active and inactive participants 2021-01-01 526
2020: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 567
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 580
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 580
2019: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 603
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 567
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 2
Total of all active and inactive participants 2019-01-01 569
2018: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 616
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 629
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 632
2017: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 596
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 643
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 2
Total of all active and inactive participants 2017-01-01 645
2016: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 570
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 596
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 2016-01-01 596
2015: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 570
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 570
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 2015-01-01 570

Measure	Date	Value
2022: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	524
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	533
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	1
Total of all active and inactive participants	2022-01-01	534
2021: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	580
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	524
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	2
Total of all active and inactive participants	2021-01-01	526
2020: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	567
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	580
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	580
2019: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	603
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	567
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	2
Total of all active and inactive participants	2019-01-01	569
2018: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	616
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	629
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	632
2017: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	596
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	643
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	2
Total of all active and inactive participants	2017-01-01	645
2016: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	570
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	596
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	596
2015: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	570
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	570
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	570

Form 5500 Responses for MILLER POULTRY EMPLOYEE BENEFIT PLAN

2022: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MILLER POULTRY EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	85
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $740
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $740
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	353
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,949
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $39,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,949
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	97
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,522
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,522
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	161
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,247
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,247
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201187073020

Policy instance

Insurance contract or identification number	201187073020
Number of Individuals Covered	177
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,526
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,526
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-018136-00

Policy instance

Insurance contract or identification number	01-018136-00
Number of Individuals Covered	533
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,848
Total amount of fees paid to insurance company	USD $418
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $38,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,848
Amount paid for insurance broker fees	418
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	39
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,394
Total amount of fees paid to insurance company	USD $185
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $10,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,394
Insurance broker organization code?	3
Amount paid for insurance broker fees	185
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	32
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,043
Total amount of fees paid to insurance company	USD $231
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $11,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,043
Insurance broker organization code?	3
Amount paid for insurance broker fees	231
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	14
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,553
Total amount of fees paid to insurance company	USD $160
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,553
Insurance broker organization code?	3
Amount paid for insurance broker fees	160
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	14
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,035
Total amount of fees paid to insurance company	USD $179
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,035
Insurance broker organization code?	3
Amount paid for insurance broker fees	179
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	82
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,338
Total amount of fees paid to insurance company	USD $377
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $18,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,338
Insurance broker organization code?	3
Amount paid for insurance broker fees	377
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	42
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,322
Total amount of fees paid to insurance company	USD $249
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $14,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,322
Insurance broker organization code?	3
Amount paid for insurance broker fees	249
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	45
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,536
Total amount of fees paid to insurance company	USD $445
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,536
Insurance broker organization code?	3
Amount paid for insurance broker fees	445

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	35
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,540
Total amount of fees paid to insurance company	USD $342
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,540
Insurance broker organization code?	3
Amount paid for insurance broker fees	342

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-018136-00

Policy instance

Insurance contract or identification number	01-018136-00
Number of Individuals Covered	524
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,454
Total amount of fees paid to insurance company	USD $340
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,454
Amount paid for insurance broker fees	340
Additional information about fees paid to insurance broker	GROUP VOLUME BONUS
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201187073020

Policy instance

Insurance contract or identification number	201187073020
Number of Individuals Covered	201
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,963
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,963
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	238
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,030
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,030
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	70
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,894
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,894
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	67
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,863
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $38,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,863
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	44
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,851
Total amount of fees paid to insurance company	USD $106
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $10,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,851
Insurance broker organization code?	3
Amount paid for insurance broker fees	106
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	40
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,057
Total amount of fees paid to insurance company	USD $132
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $13,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,057
Insurance broker organization code?	3
Amount paid for insurance broker fees	132
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,541
Total amount of fees paid to insurance company	USD $122
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,541
Insurance broker organization code?	3
Amount paid for insurance broker fees	122
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	56
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $18,144
Total amount of fees paid to insurance company	USD $186
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,144
Insurance broker organization code?	3
Amount paid for insurance broker fees	186
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	67
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $18,134
Total amount of fees paid to insurance company	USD $239
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	239
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $18,134

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	49
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,452
Total amount of fees paid to insurance company	USD $126
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $13,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,452
Insurance broker organization code?	3
Amount paid for insurance broker fees	126
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49459

Policy instance

Insurance contract or identification number	49459
Number of Individuals Covered	113
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,201
Total amount of fees paid to insurance company	USD $222
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $22,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,201
Insurance broker organization code?	3
Amount paid for insurance broker fees	222
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

49238

Policy instance

Insurance contract or identification number	49238
Number of Individuals Covered	17
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,149
Total amount of fees paid to insurance company	USD $100
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,149
Insurance broker organization code?	3
Amount paid for insurance broker fees	100
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-018136-00

Policy instance

Insurance contract or identification number	01-018136-00
Number of Individuals Covered	580
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,902
Total amount of fees paid to insurance company	USD $699
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,902
Amount paid for insurance broker fees	699
Additional information about fees paid to insurance broker	GROUP VOLUME BONUS
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	157
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,057
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,057
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201187073020

Policy instance

Insurance contract or identification number	201187073020
Number of Individuals Covered	197
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,646
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,646
Insurance broker organization code?	3

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

Policy contract number

KKA84

Policy instance

Insurance contract or identification number	KKA84
Number of Individuals Covered	77
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,928
Total amount of fees paid to insurance company	USD $253
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $61,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,055
Amount paid for insurance broker fees	36
Insurance broker organization code?	3

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

Policy contract number

KKA86

Policy instance

Insurance contract or identification number	KKA86
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,979
Total amount of fees paid to insurance company	USD $39
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $27,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $659
Amount paid for insurance broker fees	6
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	75
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $799
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $799
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	66
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,884
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,884
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	338
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,890
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $38,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,890
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	346
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,734
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $37,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,734
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	71
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,945
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,945
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	72
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $694
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $661
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967423

Policy instance

Insurance contract or identification number	OK967423
Number of Individuals Covered	567
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $318
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $318
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965848

Policy instance

Insurance contract or identification number	FLX965848
Number of Individuals Covered	567
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,289
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,289
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK751516

Policy instance

Insurance contract or identification number	LK751516
Number of Individuals Covered	50
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,258
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,258
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964039

Policy instance

Insurance contract or identification number	LK964039
Number of Individuals Covered	50
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,144
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,144
Insurance broker organization code?	3

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

Policy contract number

KKA86

Policy instance

Insurance contract or identification number	KKA86
Number of Individuals Covered	30
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,437
Total amount of fees paid to insurance company	USD $340
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $36,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $953
Amount paid for insurance broker fees	58
Insurance broker organization code?	3

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

Policy contract number

KKA84

Policy instance

Insurance contract or identification number	KKA84
Number of Individuals Covered	94
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,746
Total amount of fees paid to insurance company	USD $678
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $70,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,642
Amount paid for insurance broker fees	148
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201187073020

Policy instance

Insurance contract or identification number	201187073020
Number of Individuals Covered	197
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,873
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,873
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	230
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,728
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,630
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967423

Policy instance

Insurance contract or identification number	OK967423
Number of Individuals Covered	629
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $250
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $250
Insurance broker organization code?	3

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	225
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,771
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,771
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	71
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,447
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,447
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	364
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,784
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $37,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,784
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965848

Policy instance

Insurance contract or identification number	FLX965848
Number of Individuals Covered	629
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,802
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,802
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK751516

Policy instance

Insurance contract or identification number	LK751516
Number of Individuals Covered	56
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,017
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,017
Insurance broker organization code?	3

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

Policy contract number

KKA86

Policy instance

Insurance contract or identification number	KKA86
Number of Individuals Covered	38
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,127
Total amount of fees paid to insurance company	USD $1,666
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $34,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,160
Amount paid for insurance broker fees	349
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201187073020

Policy instance

Insurance contract or identification number	201187073020
Number of Individuals Covered	186
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,769
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,769
Insurance broker organization code?	3

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

Policy contract number

KKA84

Policy instance

Insurance contract or identification number	KKA84
Number of Individuals Covered	106
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $14,663
Total amount of fees paid to insurance company	USD $2,801
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $62,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,384
Amount paid for insurance broker fees	723
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964039

Policy instance

Insurance contract or identification number	LK964039
Number of Individuals Covered	56
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,749
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,749
Insurance broker organization code?	3

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

Policy contract number

1001044

Policy instance

Insurance contract or identification number	1001044
Number of Individuals Covered	677
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,817
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT BEN
Welfare Benefit Premiums Paid to Carrier	USD $38,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,817
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

201188663020

Policy instance

Insurance contract or identification number	201188663020
Number of Individuals Covered	68
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,073
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,073
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

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

Policy contract number

12278419

Policy instance

Insurance contract or identification number	12278419
Number of Individuals Covered	232
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,797
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,797
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK967423

Policy instance

Insurance contract or identification number	OK967423
Number of Individuals Covered	643
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $330
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $330
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965848

Policy instance

Insurance contract or identification number	FLX965848
Number of Individuals Covered	643
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,349
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,349
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK751516

Policy instance

Insurance contract or identification number	LK751516
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $952
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $952
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

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

Policy contract number

KKA86

Policy instance

Insurance contract or identification number	KKA86
Number of Individuals Covered	41
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,225
Total amount of fees paid to insurance company	USD $3
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $34,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,143
Amount paid for insurance broker fees	3
Insurance broker organization code?	3
Insurance broker name	HOLLY JEAN ROSSWURM

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

Policy contract number

KKA84

Policy instance

Insurance contract or identification number	KKA84
Number of Individuals Covered	146
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $42,967
Total amount of fees paid to insurance company	USD $7
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $88,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,981
Insurance broker organization code?	3
Amount paid for insurance broker fees	5
Insurance broker name	MICHELLE L SEXTON

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK964039

Policy instance

Insurance contract or identification number	LK964039
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,672
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,672
Insurance broker organization code?	3
Insurance broker name	CAIRNSTONE FINANCIAL LLC

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Company Name:	MILLER POULTRY EMPLOYEE BENEFIT PLAN
Employer identification number (EIN):	350175710
NAIC Classification:	315220
NAIC Description:	Men's and Boys' Cut and Sew Apparel Manufacturing