401k Plan data: FIRST SAVINGS BANK SECTION 125 PLAN plan

FIRST SAVINGS BANK SECTION 125 PLAN 401k Plan overview

Plan Name	FIRST SAVINGS BANK SECTION 125 PLAN
Plan identification number	501

FIRST SAVINGS BANK SECTION 125 PLAN Benefits

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

401k Sponsoring company profile

FIRST SAVINGS BANK has sponsored the creation of one or more 401k plans.

Company Name: FIRST SAVINGS BANK

Employer identification number (EIN): 350309764

NAIC Classification: 522110
NAIC Description: Commercial Banking

Additional information about FIRST SAVINGS BANK

Jurisdiction of Incorporation: Indiana Secretary of State

Incorporation Date:

Company Identification Number: 014123000582

More information about FIRST SAVINGS BANK

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST SAVINGS BANK SECTION 125 PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-05-01 JACKIE JOURNELL 2023-11-16
501 2021-05-01 JACKIE JOURNELL 2022-11-01
501 2020-05-01 JACKIE JOURNELL 2021-11-08
501 2019-05-01 JACKIE JOURNELL 2020-11-25
501 2018-05-01 JOHN P. LAWSON, JR. 2019-11-21
501 2017-05-01
501 2016-05-01
501 2015-10-01
501 2014-10-01
501 2013-10-01
501 2012-10-01 JOHN P. LAWSON, JR.
501 2011-10-01 JOHN P. LAWSON, JR.

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-05-01	JACKIE JOURNELL	2023-11-16
501	2021-05-01	JACKIE JOURNELL	2022-11-01
501	2020-05-01	JACKIE JOURNELL	2021-11-08
501	2019-05-01	JACKIE JOURNELL	2020-11-25
501	2018-05-01	JOHN P. LAWSON, JR.	2019-11-21
501	2017-05-01
501	2016-05-01
501	2015-10-01
501	2014-10-01
501	2013-10-01
501	2012-10-01	JOHN P. LAWSON, JR.
501	2011-10-01	JOHN P. LAWSON, JR.

Plan Statistics for FIRST SAVINGS BANK SECTION 125 PLAN

401k plan membership statisitcs for FIRST SAVINGS BANK SECTION 125 PLAN

Measure Date Value
2022: FIRST SAVINGS BANK SECTION 125 PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 510
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 379
Number of retired or separated participants receiving benefits 2022-05-01 8
Total of all active and inactive participants 2022-05-01 387
2021: FIRST SAVINGS BANK SECTION 125 PLAN 2021 401k membership
Total participants, beginning-of-year 2021-05-01 585
Total number of active participants reported on line 7a of the Form 5500 2021-05-01 520
Number of retired or separated participants receiving benefits 2021-05-01 5
Total of all active and inactive participants 2021-05-01 525
2020: FIRST SAVINGS BANK SECTION 125 PLAN 2020 401k membership
Total participants, beginning-of-year 2020-05-01 520
Total number of active participants reported on line 7a of the Form 5500 2020-05-01 585
Number of retired or separated participants receiving benefits 2020-05-01 6
Total of all active and inactive participants 2020-05-01 591
2019: FIRST SAVINGS BANK SECTION 125 PLAN 2019 401k membership
Total participants, beginning-of-year 2019-05-01 367
Total number of active participants reported on line 7a of the Form 5500 2019-05-01 506
Number of retired or separated participants receiving benefits 2019-05-01 6
Total of all active and inactive participants 2019-05-01 512
2018: FIRST SAVINGS BANK SECTION 125 PLAN 2018 401k membership
Total participants, beginning-of-year 2018-05-01 210
Total number of active participants reported on line 7a of the Form 5500 2018-05-01 351
Number of retired or separated participants receiving benefits 2018-05-01 5
Total of all active and inactive participants 2018-05-01 356
2017: FIRST SAVINGS BANK SECTION 125 PLAN 2017 401k membership
Total participants, beginning-of-year 2017-05-01 171
Total number of active participants reported on line 7a of the Form 5500 2017-05-01 200
Number of retired or separated participants receiving benefits 2017-05-01 3
Total of all active and inactive participants 2017-05-01 203
2016: FIRST SAVINGS BANK SECTION 125 PLAN 2016 401k membership
Total participants, beginning-of-year 2016-05-01 154
Total number of active participants reported on line 7a of the Form 5500 2016-05-01 170
Number of retired or separated participants receiving benefits 2016-05-01 3
Total of all active and inactive participants 2016-05-01 173
2015: FIRST SAVINGS BANK SECTION 125 PLAN 2015 401k membership
Total participants, beginning-of-year 2015-10-01 149
Total number of active participants reported on line 7a of the Form 5500 2015-10-01 153
Number of retired or separated participants receiving benefits 2015-10-01 2
Total of all active and inactive participants 2015-10-01 155
2014: FIRST SAVINGS BANK SECTION 125 PLAN 2014 401k membership
Total participants, beginning-of-year 2014-10-01 155
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 145
Number of retired or separated participants receiving benefits 2014-10-01 4
Total of all active and inactive participants 2014-10-01 149
2013: FIRST SAVINGS BANK SECTION 125 PLAN 2013 401k membership
Total participants, beginning-of-year 2013-10-01 172
Total number of active participants reported on line 7a of the Form 5500 2013-10-01 150
Number of retired or separated participants receiving benefits 2013-10-01 5
Total of all active and inactive participants 2013-10-01 155
2012: FIRST SAVINGS BANK SECTION 125 PLAN 2012 401k membership
Total participants, beginning-of-year 2012-10-01 170
Total number of active participants reported on line 7a of the Form 5500 2012-10-01 161
Number of retired or separated participants receiving benefits 2012-10-01 11
Total of all active and inactive participants 2012-10-01 172
2011: FIRST SAVINGS BANK SECTION 125 PLAN 2011 401k membership
Total participants, beginning-of-year 2011-10-01 164
Total number of active participants reported on line 7a of the Form 5500 2011-10-01 149
Number of retired or separated participants receiving benefits 2011-10-01 10
Total of all active and inactive participants 2011-10-01 159

Measure	Date	Value
2022: FIRST SAVINGS BANK SECTION 125 PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	510
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	379
Number of retired or separated participants receiving benefits	2022-05-01	8
Total of all active and inactive participants	2022-05-01	387
2021: FIRST SAVINGS BANK SECTION 125 PLAN 2021 401k membership
Total participants, beginning-of-year	2021-05-01	585
Total number of active participants reported on line 7a of the Form 5500	2021-05-01	520
Number of retired or separated participants receiving benefits	2021-05-01	5
Total of all active and inactive participants	2021-05-01	525
2020: FIRST SAVINGS BANK SECTION 125 PLAN 2020 401k membership
Total participants, beginning-of-year	2020-05-01	520
Total number of active participants reported on line 7a of the Form 5500	2020-05-01	585
Number of retired or separated participants receiving benefits	2020-05-01	6
Total of all active and inactive participants	2020-05-01	591
2019: FIRST SAVINGS BANK SECTION 125 PLAN 2019 401k membership
Total participants, beginning-of-year	2019-05-01	367
Total number of active participants reported on line 7a of the Form 5500	2019-05-01	506
Number of retired or separated participants receiving benefits	2019-05-01	6
Total of all active and inactive participants	2019-05-01	512
2018: FIRST SAVINGS BANK SECTION 125 PLAN 2018 401k membership
Total participants, beginning-of-year	2018-05-01	210
Total number of active participants reported on line 7a of the Form 5500	2018-05-01	351
Number of retired or separated participants receiving benefits	2018-05-01	5
Total of all active and inactive participants	2018-05-01	356
2017: FIRST SAVINGS BANK SECTION 125 PLAN 2017 401k membership
Total participants, beginning-of-year	2017-05-01	171
Total number of active participants reported on line 7a of the Form 5500	2017-05-01	200
Number of retired or separated participants receiving benefits	2017-05-01	3
Total of all active and inactive participants	2017-05-01	203
2016: FIRST SAVINGS BANK SECTION 125 PLAN 2016 401k membership
Total participants, beginning-of-year	2016-05-01	154
Total number of active participants reported on line 7a of the Form 5500	2016-05-01	170
Number of retired or separated participants receiving benefits	2016-05-01	3
Total of all active and inactive participants	2016-05-01	173
2015: FIRST SAVINGS BANK SECTION 125 PLAN 2015 401k membership
Total participants, beginning-of-year	2015-10-01	149
Total number of active participants reported on line 7a of the Form 5500	2015-10-01	153
Number of retired or separated participants receiving benefits	2015-10-01	2
Total of all active and inactive participants	2015-10-01	155
2014: FIRST SAVINGS BANK SECTION 125 PLAN 2014 401k membership
Total participants, beginning-of-year	2014-10-01	155
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	145
Number of retired or separated participants receiving benefits	2014-10-01	4
Total of all active and inactive participants	2014-10-01	149
2013: FIRST SAVINGS BANK SECTION 125 PLAN 2013 401k membership
Total participants, beginning-of-year	2013-10-01	172
Total number of active participants reported on line 7a of the Form 5500	2013-10-01	150
Number of retired or separated participants receiving benefits	2013-10-01	5
Total of all active and inactive participants	2013-10-01	155
2012: FIRST SAVINGS BANK SECTION 125 PLAN 2012 401k membership
Total participants, beginning-of-year	2012-10-01	170
Total number of active participants reported on line 7a of the Form 5500	2012-10-01	161
Number of retired or separated participants receiving benefits	2012-10-01	11
Total of all active and inactive participants	2012-10-01	172
2011: FIRST SAVINGS BANK SECTION 125 PLAN 2011 401k membership
Total participants, beginning-of-year	2011-10-01	164
Total number of active participants reported on line 7a of the Form 5500	2011-10-01	149
Number of retired or separated participants receiving benefits	2011-10-01	10
Total of all active and inactive participants	2011-10-01	159

Form 5500 Responses for FIRST SAVINGS BANK SECTION 125 PLAN

2022: FIRST SAVINGS BANK SECTION 125 PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2021: FIRST SAVINGS BANK SECTION 125 PLAN 2021 form 5500 responses
2021-05-01	Type of plan entity	Single employer plan
2021-05-01	Plan funding arrangement – Insurance	Yes
2021-05-01	Plan benefit arrangement – Insurance	Yes
2020: FIRST SAVINGS BANK SECTION 125 PLAN 2020 form 5500 responses
2020-05-01	Type of plan entity	Single employer plan
2020-05-01	Plan funding arrangement – Insurance	Yes
2020-05-01	Plan benefit arrangement – Insurance	Yes
2019: FIRST SAVINGS BANK SECTION 125 PLAN 2019 form 5500 responses
2019-05-01	Type of plan entity	Single employer plan
2019-05-01	Plan funding arrangement – Insurance	Yes
2019-05-01	Plan benefit arrangement – Insurance	Yes
2018: FIRST SAVINGS BANK SECTION 125 PLAN 2018 form 5500 responses
2018-05-01	Type of plan entity	Single employer plan
2018-05-01	Plan funding arrangement – Insurance	Yes
2018-05-01	Plan benefit arrangement – Insurance	Yes
2017: FIRST SAVINGS BANK SECTION 125 PLAN 2017 form 5500 responses
2017-05-01	Type of plan entity	Single employer plan
2017-05-01	Plan funding arrangement – Insurance	Yes
2017-05-01	Plan benefit arrangement – Insurance	Yes
2016: FIRST SAVINGS BANK SECTION 125 PLAN 2016 form 5500 responses
2016-05-01	Type of plan entity	Single employer plan
2016-05-01	Plan funding arrangement – Insurance	Yes
2016-05-01	Plan benefit arrangement – Insurance	Yes
2015: FIRST SAVINGS BANK SECTION 125 PLAN 2015 form 5500 responses
2015-10-01	Type of plan entity	Single employer plan
2015-10-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-10-01	Plan funding arrangement – Insurance	Yes
2015-10-01	Plan benefit arrangement – Insurance	Yes
2014: FIRST SAVINGS BANK SECTION 125 PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2013: FIRST SAVINGS BANK SECTION 125 PLAN 2013 form 5500 responses
2013-10-01	Type of plan entity	Single employer plan
2013-10-01	Plan funding arrangement – Insurance	Yes
2013-10-01	Plan benefit arrangement – Insurance	Yes
2012: FIRST SAVINGS BANK SECTION 125 PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Plan funding arrangement – Insurance	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: FIRST SAVINGS BANK SECTION 125 PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	Plan funding arrangement – Insurance	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	625
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $5,638
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,638
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	627
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $3,188
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,188
Insurance broker organization code?	3

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

Policy contract number

GL 165601

Policy instance

Insurance contract or identification number	GL 165601
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $6,516
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $65,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,516
Insurance broker organization code?	3

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

Policy contract number

0DP47

Policy instance

Insurance contract or identification number	0DP47
Number of Individuals Covered	164
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $43,725
Total amount of fees paid to insurance company	USD $1,044
Other welfare benefits provided	CANCER, INTENSIVE CARE, SPEC EVENT
Welfare Benefit Premiums Paid to Carrier	USD $196,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14
Insurance broker organization code?	3
Amount paid for insurance broker fees	262
Additional information about fees paid to insurance broker	OTHER

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

Policy contract number

0NJT8

Policy instance

Insurance contract or identification number	0NJT8
Number of Individuals Covered	146
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $19,909
Total amount of fees paid to insurance company	USD $183
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	CNCR, HSP, ACCDNT, STD, SPC EVNT IC
Welfare Benefit Premiums Paid to Carrier	USD $120,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,242
Amount paid for insurance broker fees	72
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

L02694

Policy instance

Insurance contract or identification number	L02694
Number of Individuals Covered	535
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $108,612
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,977,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108,612
Insurance broker organization code?	3

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

Policy contract number

GL 165750

Policy instance

Insurance contract or identification number	GL 165750
Number of Individuals Covered	509
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $5,515
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $55,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,515
Insurance broker organization code?	3

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

Policy contract number

LTD 133768

Policy instance

Insurance contract or identification number	LTD 133768
Number of Individuals Covered	425
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $5,849
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,849
Insurance broker organization code?	3

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

Policy contract number

VAR 210148

Policy instance

Insurance contract or identification number	VAR 210148
Number of Individuals Covered	482
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $795
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $795
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	838
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $3,748
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,748
Insurance broker organization code?	3

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	829
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $6,723
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,723
Insurance broker organization code?	3

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

Policy contract number

0DP47

Policy instance

Insurance contract or identification number	0DP47
Number of Individuals Covered	171
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $34,240
Total amount of fees paid to insurance company	USD $435
Other welfare benefits provided	CANCER, INTENSIVE CARE, SPEC EVENT
Welfare Benefit Premiums Paid to Carrier	USD $178,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,531
Insurance broker organization code?	3
Amount paid for insurance broker fees	160
Additional information about fees paid to insurance broker	OTHER

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

Policy contract number

01-017980-00

Policy instance

Insurance contract or identification number	01-017980-00
Number of Individuals Covered	520
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $20,513
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $204,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,513
Insurance broker organization code?	3

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

Policy contract number

0NJT8

Policy instance

Insurance contract or identification number	0NJT8
Number of Individuals Covered	136
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $16,072
Total amount of fees paid to insurance company	USD $85
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	CNCR, HSP, ACCDNT, STD, SPC EVNT IC
Welfare Benefit Premiums Paid to Carrier	USD $116,743
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	OTHER

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

L02694

Policy instance

Insurance contract or identification number	L02694
Number of Individuals Covered	709
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $121,016
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,562,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $121,016
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

826130

Policy instance

Insurance contract or identification number	826130
Number of Individuals Covered	2
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $869
Total amount of fees paid to insurance company	USD $19
Welfare Benefit Premiums Paid to Carrier	USD $34,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $869
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	847
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $6,926
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,926
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	851
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $4,238
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,238
Insurance broker organization code?	3

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

Policy contract number

01-017980-00

Policy instance

Insurance contract or identification number	01-017980-00
Number of Individuals Covered	585
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $16,548
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $164,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,548
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

826130

Policy instance

Insurance contract or identification number	826130
Number of Individuals Covered	411
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $126,943
Total amount of fees paid to insurance company	USD $3,561
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,950,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126,943
Amount paid for insurance broker fees	3561
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

0DP47

Policy instance

Insurance contract or identification number	0DP47
Number of Individuals Covered	150
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $32,098
Total amount of fees paid to insurance company	USD $827
Other welfare benefits provided	CANCER, INTENSIVE CARE, SPEC EVENT
Welfare Benefit Premiums Paid to Carrier	USD $172,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,037
Insurance broker organization code?	3
Amount paid for insurance broker fees	94
Additional information about fees paid to insurance broker	OTHER

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

Policy contract number

0NJT8

Policy instance

Insurance contract or identification number	0NJT8
Number of Individuals Covered	137
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $19,856
Total amount of fees paid to insurance company	USD $490
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	CNCR, HSP, ACCDNT, STD, SPC EVNT IC
Welfare Benefit Premiums Paid to Carrier	USD $124,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,382
Insurance broker organization code?	3
Amount paid for insurance broker fees	281
Additional information about fees paid to insurance broker	OTHER

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

826130

Policy instance

Insurance contract or identification number	826130
Number of Individuals Covered	1
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $608
Total amount of fees paid to insurance company	USD $12
Welfare Benefit Premiums Paid to Carrier	USD $18,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	806
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $3,216
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,216
Insurance broker organization code?	3

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	795
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $12,953
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,953
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

826130

Policy instance

Insurance contract or identification number	826130
Number of Individuals Covered	374
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $99,156
Total amount of fees paid to insurance company	USD $2,935
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,028,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $99,156
Amount paid for insurance broker fees	2935
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	3

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

Policy contract number

01-017980-00

Policy instance

Insurance contract or identification number	01-017980-00
Number of Individuals Covered	506
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $13,889
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $138,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,889
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	598
Insurance policy start date	2018-05-01
Insurance policy end date	2019-04-30
Total amount of commissions paid to insurance broker	USD $2,010
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,010
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	351
Insurance policy start date	2018-05-01
Insurance policy end date	2019-04-30
Total amount of commissions paid to insurance broker	USD $12,753
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,753
Insurance broker organization code?	3

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	604
Insurance policy start date	2018-05-01
Insurance policy end date	2019-04-30
Total amount of commissions paid to insurance broker	USD $5,872
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,872
Insurance broker organization code?	3

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

Policy contract number

98567411001

Policy instance

Insurance contract or identification number	98567411001
Number of Individuals Covered	355
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $1,434
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,434
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON INSURANCE GROUP

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	373
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $8,465
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,465
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	359
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $4,216
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,216
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL SERVICES

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

Policy contract number

SGD602596

Policy instance

Insurance contract or identification number	SGD602596
Number of Individuals Covered	153
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $1,056
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,056
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

9856741

Policy instance

Insurance contract or identification number	9856741
Number of Individuals Covered	289
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $731
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $731
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON INSURANCE GROUP

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

Policy contract number

SGM602692

Policy instance

Insurance contract or identification number	SGM602692
Number of Individuals Covered	153
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $3,540
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,600
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
Insurance broker name	ROBERT H CLARKSON INSURANCE

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	152
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $188
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $188
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	281
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $2,306
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,306
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SOK601656

Policy instance

Insurance contract or identification number	SOK601656
Number of Individuals Covered	153
Insurance policy start date	2015-10-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $329
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $2,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SGM602692

Policy instance

Insurance contract or identification number	SGM602692
Number of Individuals Covered	145
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $5,183
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,183
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	147
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $310
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $310
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL

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

Policy contract number

SGD602596

Policy instance

Insurance contract or identification number	SGD602596
Number of Individuals Covered	145
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $1,558
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,558
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

9856741

Policy instance

Insurance contract or identification number	9856741
Number of Individuals Covered	272
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $1,188
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,188
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON INSURANCE GROUP

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

Policy contract number

SOK601656

Policy instance

Insurance contract or identification number	SOK601656
Number of Individuals Covered	145
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $490
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $3,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $490
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	269
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $3,097
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,097
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SGM602692

Policy instance

Insurance contract or identification number	SGM602692
Number of Individuals Covered	150
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $5,104
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,104
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

9856741

Policy instance

Insurance contract or identification number	9856741
Number of Individuals Covered	245
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,084
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,084
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON INSURANCE GROUP

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	262
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $4,038
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,038
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SGD602596

Policy instance

Insurance contract or identification number	SGD602596
Number of Individuals Covered	150
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,563
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,563
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	149
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $329
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL

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

Policy contract number

SOK601656

Policy instance

Insurance contract or identification number	SOK601656
Number of Individuals Covered	150
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $493
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $3,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $493
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SGM602692

Policy instance

Insurance contract or identification number	SGM602692
Number of Individuals Covered	161
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $5,132
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,132
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

9856741

Policy instance

Insurance contract or identification number	9856741
Number of Individuals Covered	147
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,252
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,252
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON INSURANCE GROUP

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

Policy contract number

SGD602596

Policy instance

Insurance contract or identification number	SGD602596
Number of Individuals Covered	161
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,512
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,512
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00235427

Policy instance

Insurance contract or identification number	00235427
Number of Individuals Covered	119
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $28,820
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $833,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,820
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL SERVICES

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	281
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $3,127
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,127
Insurance broker organization code?	3
Insurance broker name	RH CLARKSON FINANCIAL

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

Policy contract number

SOK601656

Policy instance

Insurance contract or identification number	SOK601656
Number of Individuals Covered	161
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $495
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $3,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $495
Insurance broker organization code?	3
Insurance broker name	ROBERT H CLARKSON INSURANCE

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

Policy contract number

SGM602692

Policy instance

Insurance contract or identification number	SGM602692
Number of Individuals Covered	149
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $4,129
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00195110

Policy instance

Insurance contract or identification number	00195110
Number of Individuals Covered	0
Insurance policy start date	2011-10-01
Insurance policy end date	2011-10-14
Total amount of commissions paid to insurance broker	USD $83
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

29357

Policy instance

Insurance contract or identification number	29357
Number of Individuals Covered	259
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $1,125
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 )

Policy contract number

151

Policy instance

Insurance contract or identification number	151
Number of Individuals Covered	286
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $3,177
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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

742992

Policy instance

Insurance contract or identification number	742992
Number of Individuals Covered	272
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $38,351
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $763,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SOK601656

Policy instance

Insurance contract or identification number	SOK601656
Number of Individuals Covered	149
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $381
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $2,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00195110

Policy instance

Insurance contract or identification number	00195110
Number of Individuals Covered	143
Insurance policy start date	2010-12-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $344
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

308761

Policy instance

Insurance contract or identification number	308761
Number of Individuals Covered	192
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $5,330
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $44,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

29357

Policy instance

Insurance contract or identification number	29357
Number of Individuals Covered	247
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $1,157
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

TM05756316

Policy instance

Insurance contract or identification number	TM05756316
Number of Individuals Covered	398
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $2,733
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00195110

Policy instance

Insurance contract or identification number	00195110
Number of Individuals Covered	220
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $27,202
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $846,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00195110

Policy instance

Insurance contract or identification number	00195110
Number of Individuals Covered	190
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $33,011
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $687,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,980
Insurance broker organization code?	3
Insurance broker name	INDIANA CHAMBER INSURANCE AGENCY

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00195110

Policy instance

Insurance contract or identification number	00195110
Number of Individuals Covered	128
Insurance policy start date	2009-12-01
Insurance policy end date	2009-11-30
Total amount of commissions paid to insurance broker	USD $378
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $378
Insurance broker organization code?	3
Insurance broker name	R H CLARKSON FINANCIAL SERVICES

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

Policy contract number

TM05756316

Policy instance

Insurance contract or identification number	TM05756316
Number of Individuals Covered	331
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $2,288
Total amount of fees paid to insurance company	USD $227
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,288
Amount paid for insurance broker fees	227
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	R H CLARKSON FINANCIAL SERVICES

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

308761

Policy instance

Insurance contract or identification number	308761
Number of Individuals Covered	172
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $4,839
Total amount of fees paid to insurance company	USD $1,276
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,839
Insurance broker organization code?	3
Amount paid for insurance broker fees	767
Additional information about fees paid to insurance broker	2009 NEW BUSINESS GROUP INS BONUS-TERM LIFE
Insurance broker name	R H CLARKSON FINANCIAL SERVICES

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

29357

Policy instance

Insurance contract or identification number	29357
Number of Individuals Covered	216
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $933
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Insurance broker organization code?	3
Insurance broker name	R H CLARKSON FINANCIAL SERVICES

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Company Name:	FIRST SAVINGS BANK
Employer identification number (EIN):	350309764
NAIC Classification:	522110
NAIC Description:	Commercial Banking

Jurisdiction of Incorporation:	Indiana Secretary of State
Incorporation Date:
Company Identification Number:	014123000582