401k Plan data: THORNTONS EMPLOYEE INSURANCE PLAN plan

THORNTONS EMPLOYEE INSURANCE PLAN 401k Plan overview

Plan Name	THORNTONS EMPLOYEE INSURANCE PLAN
Plan identification number	501

THORNTONS EMPLOYEE INSURANCE 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

THORNTONS LLC has sponsored the creation of one or more 401k plans.

Company Name: THORNTONS LLC

Employer identification number (EIN): 351188206

NAIC Classification: 447100
NAIC Description: Gasoline Stations, Gas

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THORNTONS EMPLOYEE INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-03-01 SANDY DEEL 2023-11-09
501 2022-03-01 SANDY DEEL 2023-10-26
501 2021-03-01 SHELLY GIBSON 2022-10-12
501 2020-03-01 SHELLY GIBSON 2021-09-21
501 2019-03-01 SHELLY GIBSON 2020-09-09
501 2018-03-01 SANDY DEEL 2019-10-16
501 2017-03-01
501 2016-03-01
501 2015-03-01
501 2014-03-01
501 2013-03-01
501 2012-03-01 DEBRA WEATHERFORD DEBRA WEATHERFORD 2013-09-30
501 2012-01-01 DEBRA WEATHERFORD DEBRA WEATHERFORD 2013-09-27
501 2011-03-01 DEBRA WEATHERFORD
501 2009-03-01 DEBRA WEATHERFORD
501 2009-03-01 DEBRA WEATHERFORD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-03-01	SANDY DEEL	2023-11-09
501	2022-03-01	SANDY DEEL	2023-10-26
501	2021-03-01	SHELLY GIBSON	2022-10-12
501	2020-03-01	SHELLY GIBSON	2021-09-21
501	2019-03-01	SHELLY GIBSON	2020-09-09
501	2018-03-01	SANDY DEEL	2019-10-16
501	2017-03-01
501	2016-03-01
501	2015-03-01
501	2014-03-01
501	2013-03-01
501	2012-03-01	DEBRA WEATHERFORD		DEBRA WEATHERFORD	2013-09-30
501	2012-01-01	DEBRA WEATHERFORD		DEBRA WEATHERFORD	2013-09-27
501	2011-03-01	DEBRA WEATHERFORD
501	2009-03-01	DEBRA WEATHERFORD
501	2009-03-01	DEBRA WEATHERFORD

Plan Statistics for THORNTONS EMPLOYEE INSURANCE PLAN

401k plan membership statisitcs for THORNTONS EMPLOYEE INSURANCE PLAN

Measure Date Value
2023: THORNTONS EMPLOYEE INSURANCE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-03-01 1,096
Total number of active participants reported on line 7a of the Form 5500 2023-03-01 0
Total of all active and inactive participants 2023-03-01 0
2022: THORNTONS EMPLOYEE INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-03-01 956
Total number of active participants reported on line 7a of the Form 5500 2022-03-01 1,096
Total of all active and inactive participants 2022-03-01 1,096
2021: THORNTONS EMPLOYEE INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-03-01 853
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 956
Total of all active and inactive participants 2021-03-01 956
2020: THORNTONS EMPLOYEE INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-03-01 850
Total number of active participants reported on line 7a of the Form 5500 2020-03-01 853
Total of all active and inactive participants 2020-03-01 853
2019: THORNTONS EMPLOYEE INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-03-01 819
Total number of active participants reported on line 7a of the Form 5500 2019-03-01 850
Total of all active and inactive participants 2019-03-01 850
2018: THORNTONS EMPLOYEE INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-03-01 890
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 819
Total of all active and inactive participants 2018-03-01 819
2017: THORNTONS EMPLOYEE INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-03-01 884
Total number of active participants reported on line 7a of the Form 5500 2017-03-01 890
Total of all active and inactive participants 2017-03-01 890
Total participants 2017-03-01 890
2016: THORNTONS EMPLOYEE INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 841
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 884
Total of all active and inactive participants 2016-03-01 884
Total participants 2016-03-01 884
2015: THORNTONS EMPLOYEE INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 630
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 841
Total of all active and inactive participants 2015-03-01 841
Total participants 2015-03-01 841
2014: THORNTONS EMPLOYEE INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-03-01 723
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 630
Total of all active and inactive participants 2014-03-01 630
Total participants 2014-03-01 630
2013: THORNTONS EMPLOYEE INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-03-01 535
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 723
Total of all active and inactive participants 2013-03-01 723
2012: THORNTONS EMPLOYEE INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-03-01 510
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 535
Total of all active and inactive participants 2012-03-01 535
Total participants 2012-03-01 535
Total participants, beginning-of-year 2012-01-01 510
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 535
Total of all active and inactive participants 2012-01-01 535
Total participants 2012-01-01 535
2011: THORNTONS EMPLOYEE INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-03-01 509
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 497
Total of all active and inactive participants 2011-03-01 497
Total participants 2011-03-01 497
2009: THORNTONS EMPLOYEE INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-03-01 557
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 515
Number of retired or separated participants receiving benefits 2009-03-01 0
Number of other retired or separated participants entitled to future benefits 2009-03-01 0
Total of all active and inactive participants 2009-03-01 515
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-03-01 0
Total participants 2009-03-01 515
Number of participants with account balances 2009-03-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-03-01 0

Measure	Date	Value
2023: THORNTONS EMPLOYEE INSURANCE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-03-01	1,096
Total number of active participants reported on line 7a of the Form 5500	2023-03-01	0
Total of all active and inactive participants	2023-03-01	0
2022: THORNTONS EMPLOYEE INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-03-01	956
Total number of active participants reported on line 7a of the Form 5500	2022-03-01	1,096
Total of all active and inactive participants	2022-03-01	1,096
2021: THORNTONS EMPLOYEE INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-03-01	853
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	956
Total of all active and inactive participants	2021-03-01	956
2020: THORNTONS EMPLOYEE INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-03-01	850
Total number of active participants reported on line 7a of the Form 5500	2020-03-01	853
Total of all active and inactive participants	2020-03-01	853
2019: THORNTONS EMPLOYEE INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-03-01	819
Total number of active participants reported on line 7a of the Form 5500	2019-03-01	850
Total of all active and inactive participants	2019-03-01	850
2018: THORNTONS EMPLOYEE INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	890
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	819
Total of all active and inactive participants	2018-03-01	819
2017: THORNTONS EMPLOYEE INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	884
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	890
Total of all active and inactive participants	2017-03-01	890
Total participants	2017-03-01	890
2016: THORNTONS EMPLOYEE INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	841
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	884
Total of all active and inactive participants	2016-03-01	884
Total participants	2016-03-01	884
2015: THORNTONS EMPLOYEE INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	630
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	841
Total of all active and inactive participants	2015-03-01	841
Total participants	2015-03-01	841
2014: THORNTONS EMPLOYEE INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	723
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	630
Total of all active and inactive participants	2014-03-01	630
Total participants	2014-03-01	630
2013: THORNTONS EMPLOYEE INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	535
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	723
Total of all active and inactive participants	2013-03-01	723
2012: THORNTONS EMPLOYEE INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	510
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	535
Total of all active and inactive participants	2012-03-01	535
Total participants	2012-03-01	535
Total participants, beginning-of-year	2012-01-01	510
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	535
Total of all active and inactive participants	2012-01-01	535
Total participants	2012-01-01	535
2011: THORNTONS EMPLOYEE INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-03-01	509
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	497
Total of all active and inactive participants	2011-03-01	497
Total participants	2011-03-01	497
2009: THORNTONS EMPLOYEE INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-03-01	557
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	515
Number of retired or separated participants receiving benefits	2009-03-01	0
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	515
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-03-01	0
Total participants	2009-03-01	515
Number of participants with account balances	2009-03-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-03-01	0

Form 5500 Responses for THORNTONS EMPLOYEE INSURANCE PLAN

2023: THORNTONS EMPLOYEE INSURANCE PLAN 2023 form 5500 responses
2023-03-01	Type of plan entity	Single employer plan
2023-03-01	This submission is the final filing	Yes
2023-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2023-03-01	Plan funding arrangement – Insurance	Yes
2023-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-03-01	Plan benefit arrangement – Insurance	Yes
2023-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: THORNTONS EMPLOYEE INSURANCE PLAN 2022 form 5500 responses
2022-03-01	Type of plan entity	Single employer plan
2022-03-01	Plan funding arrangement – Insurance	Yes
2022-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-03-01	Plan benefit arrangement – Insurance	Yes
2022-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: THORNTONS EMPLOYEE INSURANCE PLAN 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THORNTONS EMPLOYEE INSURANCE PLAN 2020 form 5500 responses
2020-03-01	Type of plan entity	Single employer plan
2020-03-01	Plan funding arrangement – Insurance	Yes
2020-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-03-01	Plan benefit arrangement – Insurance	Yes
2020-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THORNTONS EMPLOYEE INSURANCE PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: THORNTONS EMPLOYEE INSURANCE PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: THORNTONS EMPLOYEE INSURANCE PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: THORNTONS EMPLOYEE INSURANCE PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: THORNTONS EMPLOYEE INSURANCE PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: THORNTONS EMPLOYEE INSURANCE PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: THORNTONS EMPLOYEE INSURANCE PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: THORNTONS EMPLOYEE INSURANCE PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	Yes
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: THORNTONS EMPLOYEE INSURANCE PLAN 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Submission has been amended	Yes
2011-03-01	This submission is the final filing	No
2011-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-03-01	Plan is a collectively bargained plan	No
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: THORNTONS EMPLOYEE INSURANCE PLAN 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Submission has been amended	Yes
2009-03-01	This submission is the final filing	No
2009-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-03-01	Plan is a collectively bargained plan	No
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	1146
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $6,888
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $68,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,888
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	793
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $2,502
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,502
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

1024030

Policy instance

Insurance contract or identification number	1024030
Number of Individuals Covered	794
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $2,286
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $65,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,286
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	1094
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $4,871
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $48,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,871
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS0010573

Policy instance

Insurance contract or identification number	AS0010573
Number of Individuals Covered	166
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $412
Total amount of fees paid to insurance company	USD $165
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $412
Amount paid for insurance broker fees	165
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	413
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $3,648
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $-131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,648
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

L05266

Policy instance

Insurance contract or identification number	L05266
Number of Individuals Covered	2721
Insurance policy start date	2023-03-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $13,919
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $709,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,919
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	805
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $10,109
Total amount of fees paid to insurance company	USD $13,649
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $288,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,109
Amount paid for insurance broker fees	13649
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

L05266

Policy instance

Insurance contract or identification number	L05266
Number of Individuals Covered	2749
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $137,723
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,742,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137,723
Insurance broker organization code?	3

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	464
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $50,001
Total amount of fees paid to insurance company	USD $16,724
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $221,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,001
Insurance broker organization code?	3
Amount paid for insurance broker fees	16724
Additional information about fees paid to insurance broker	BONUS

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS0010573

Policy instance

Insurance contract or identification number	AS0010573
Number of Individuals Covered	174
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $4,461
Total amount of fees paid to insurance company	USD $1,772
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,461
Insurance broker organization code?	3
Amount paid for insurance broker fees	1772
Additional information about fees paid to insurance broker	FEES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	1096
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $21,577
Total amount of fees paid to insurance company	USD $8,769
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $215,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,577
Amount paid for insurance broker fees	8769
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	803
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $9,359
Total amount of fees paid to insurance company	USD $10,050
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $267,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,359
Amount paid for insurance broker fees	10050
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	1175
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $30,841
Total amount of fees paid to insurance company	USD $11,300
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $308,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,841
Amount paid for insurance broker fees	11300
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	739
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $8,329
Total amount of fees paid to insurance company	USD $9,240
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $237,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,329
Amount paid for insurance broker fees	9240
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	1259
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $20,137
Total amount of fees paid to insurance company	USD $9,494
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $201,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,137
Amount paid for insurance broker fees	9494
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	739
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $6,300
Total amount of fees paid to insurance company	USD $7,880
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $180,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,300
Amount paid for insurance broker fees	7880
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1397
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $5,864
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 $5,864
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	956
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $15,188
Total amount of fees paid to insurance company	USD $6,822
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $151,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,188
Amount paid for insurance broker fees	6822
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	749
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $6,628
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,628
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	178
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $4,278
Total amount of fees paid to insurance company	USD $1,713
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,278
Insurance broker organization code?	3
Amount paid for insurance broker fees	1713
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	396
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $38,524
Total amount of fees paid to insurance company	USD $17,168
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $192,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,524
Insurance broker organization code?	3
Amount paid for insurance broker fees	17168
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	770
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $35,424
Total amount of fees paid to insurance company	USD $12,238
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,058,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,424
Amount paid for insurance broker fees	12238
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	642
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $6,697
Total amount of fees paid to insurance company	USD $8,818
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,697
Amount paid for insurance broker fees	8818
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	691
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $19,958
Total amount of fees paid to insurance company	USD $9,439
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $199,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,958
Amount paid for insurance broker fees	9439
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	642
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $5,766
Total amount of fees paid to insurance company	USD $8,061
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OPT LTD
Welfare Benefit Premiums Paid to Carrier	USD $164,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,766
Amount paid for insurance broker fees	8061
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1442
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $5,663
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 $4,878
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	853
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $14,288
Total amount of fees paid to insurance company	USD $6,267
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $142,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,288
Amount paid for insurance broker fees	6267
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	778
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $8,254
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,254
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	190
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $3,806
Total amount of fees paid to insurance company	USD $1,523
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,806
Insurance broker organization code?	3
Amount paid for insurance broker fees	1523
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	387
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $34,028
Total amount of fees paid to insurance company	USD $9,201
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $163,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,028
Amount paid for insurance broker fees	9201
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	808
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $40,265
Total amount of fees paid to insurance company	USD $11,288
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,278,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,265
Amount paid for insurance broker fees	11288
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	121
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-28
Total amount of commissions paid to insurance broker	USD $2,684
Total amount of fees paid to insurance company	USD $1,074
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,684
Insurance broker organization code?	3
Amount paid for insurance broker fees	1074
Additional information about fees paid to insurance broker	TPA FEES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	731
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $7,627
Total amount of fees paid to insurance company	USD $293
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,627
Amount paid for insurance broker fees	293
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	792
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $35,882
Total amount of fees paid to insurance company	USD $7,902
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,368,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,882
Amount paid for insurance broker fees	7894
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	850
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $13,744
Total amount of fees paid to insurance company	USD $5,570
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $137,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,744
Amount paid for insurance broker fees	5570
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1375
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $9,017
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 $9,017
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	592
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $6,454
Total amount of fees paid to insurance company	USD $12,132
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OPT LTD
Welfare Benefit Premiums Paid to Carrier	USD $184,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,454
Amount paid for insurance broker fees	12132
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	633
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $21,185
Total amount of fees paid to insurance company	USD $12,521
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $211,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,185
Amount paid for insurance broker fees	12521
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	592
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $7,086
Total amount of fees paid to insurance company	USD $12,870
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,086
Amount paid for insurance broker fees	12870
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	301
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $25,067
Total amount of fees paid to insurance company	USD $8,465
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $114,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,067
Amount paid for insurance broker fees	8465
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	681
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $5,617
Total amount of fees paid to insurance company	USD $9,634
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,617
Amount paid for insurance broker fees	9634
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	578
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $19,200
Total amount of fees paid to insurance company	USD $10,066
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $192,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,200
Amount paid for insurance broker fees	10066
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

905435

Policy instance

Insurance contract or identification number	905435
Number of Individuals Covered	267
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $22,997
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $107,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,997
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	94
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $3,021
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,157
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	668
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $8,540
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,540
Insurance broker organization code?	3

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	756
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $35,716
Total amount of fees paid to insurance company	USD $11,274
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,304,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,716
Amount paid for insurance broker fees	11274
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850498

Policy instance

Insurance contract or identification number	850498
Number of Individuals Covered	0
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $6,728
Other welfare benefits provided	VOLUNTARY AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $22,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,565
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	819
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $9,148
Total amount of fees paid to insurance company	USD $3,971
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $91,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,148
Amount paid for insurance broker fees	3971
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1379
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,755
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 $4,755
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	763
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $7,109
Total amount of fees paid to insurance company	USD $8,202
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OPT LTD
Welfare Benefit Premiums Paid to Carrier	USD $203,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,109
Amount paid for insurance broker fees	8202
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	86
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $1,772
Total amount of fees paid to insurance company	USD $715
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,772
Insurance broker organization code?	3
Amount paid for insurance broker fees	715
Additional information about fees paid to insurance broker	TPA FEES
Insurance broker name	NORTH AMERICAN BENEFITS COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	662
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $8,858
Total amount of fees paid to insurance company	USD $485
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,858
Amount paid for insurance broker fees	485
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	765
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $34,886
Total amount of fees paid to insurance company	USD $12,179
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,757,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,886
Amount paid for insurance broker fees	12179
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850498

Policy instance

Insurance contract or identification number	850498
Number of Individuals Covered	269
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $50,171
Other welfare benefits provided	VOLUNTARY AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $161,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,204
Insurance broker organization code?	3
Insurance broker name	THOMAS D CASSADY

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214029

Policy instance

Insurance contract or identification number	10214029
Number of Individuals Covered	890
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $7,910
Total amount of fees paid to insurance company	USD $4,434
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $79,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,910
Amount paid for insurance broker fees	4434
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1309
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $11,220
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 $11,220
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214030

Policy instance

Insurance contract or identification number	10214030
Number of Individuals Covered	680
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $5,879
Total amount of fees paid to insurance company	USD $10,710
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OPTIONAL LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $167,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,879
Amount paid for insurance broker fees	10710
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 20874

Policy instance

Insurance contract or identification number	400001000 20874
Number of Individuals Covered	545
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $20,559
Total amount of fees paid to insurance company	USD $12,787
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $205,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,559
Amount paid for insurance broker fees	12787
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10214031

Policy instance

Insurance contract or identification number	10214031
Number of Individuals Covered	600
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $6,783
Total amount of fees paid to insurance company	USD $11,440
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,783
Amount paid for insurance broker fees	11440
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	647
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $8,826
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,327
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	775
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $35,244
Total amount of fees paid to insurance company	USD $55,827
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,743,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,298
Amount paid for insurance broker fees	16103
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850498

Policy instance

Insurance contract or identification number	850498
Number of Individuals Covered	865
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $55,876
Other welfare benefits provided	VOLUNTARY AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $155,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,876
Insurance broker organization code?	3
Insurance broker name	THOMAS D CASSADY

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUD 0AIIA

Policy instance

Insurance contract or identification number	GUD 0AIIA
Number of Individuals Covered	655
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $5,743
Total amount of fees paid to insurance company	USD $10,025
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,743
Amount paid for insurance broker fees	10025
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1392
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $5,979
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 $5,979
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGOAIIA

Policy instance

Insurance contract or identification number	GLUGOAIIA
Number of Individuals Covered	841
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $6,959
Total amount of fees paid to insurance company	USD $3,806
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $69,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,959
Amount paid for insurance broker fees	3806
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AIIA

Policy instance

Insurance contract or identification number	GVTL0AIIA
Number of Individuals Covered	458
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $18,650
Total amount of fees paid to insurance company	USD $10,835
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $186,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,650
Amount paid for insurance broker fees	10835
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0AIIA

Policy instance

Insurance contract or identification number	GUG 0AIIA
Number of Individuals Covered	665
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $5,943
Total amount of fees paid to insurance company	USD $9,914
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,943
Amount paid for insurance broker fees	9914
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	93
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $9,915
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,915
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0A11A

Policy instance

Insurance contract or identification number	GUG0A11A
Number of Individuals Covered	630
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,907
Total amount of fees paid to insurance company	USD $3,495
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,122
Amount paid for insurance broker fees	3495
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1487
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,378
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 $5,378
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTLOAIIA

Policy instance

Insurance contract or identification number	GVTLOAIIA
Number of Individuals Covered	541
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $18,797
Total amount of fees paid to insurance company	USD $2,936
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $187,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,883
Amount paid for insurance broker fees	2936
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUD0AIIA

Policy instance

Insurance contract or identification number	GUD0AIIA
Number of Individuals Covered	630
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,885
Total amount of fees paid to insurance company	USD $3,822
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $163,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,150
Amount paid for insurance broker fees	3822
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850498

Policy instance

Insurance contract or identification number	850498
Number of Individuals Covered	249
Total amount of commissions paid to insurance broker	USD $70,745
Other welfare benefits provided	CANCER/ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $135,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,745
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGOAIIA

Policy instance

Insurance contract or identification number	GLUGOAIIA
Number of Individuals Covered	800
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $6,545
Total amount of fees paid to insurance company	USD $1,330
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $65,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,019
Amount paid for insurance broker fees	1330
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	710
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $63,370
Total amount of fees paid to insurance company	USD $64,642
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,826,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,370
Amount paid for insurance broker fees	64642
Additional information about fees paid to insurance broker	VOLUME INCENTIVES
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

KANSAS CITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0573-KCL

Policy instance

Insurance contract or identification number	AS001-0573-KCL
Number of Individuals Covered	219
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $10,907
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,907
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUD0AIIA

Policy instance

Insurance contract or identification number	GUD0AIIA
Number of Individuals Covered	624
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,985
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $173,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,985
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

DU5719

Policy instance

Insurance contract or identification number	DU5719
Number of Individuals Covered	1426
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $4,842
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,842
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGOAIIA

Policy instance

Insurance contract or identification number	GLUGOAIIA
Number of Individuals Covered	723
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $6,001
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,001
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTLOAIIA

Policy instance

Insurance contract or identification number	GVTLOAIIA
Number of Individuals Covered	420
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $13,909
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $139,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,909
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0A11A

Policy instance

Insurance contract or identification number	GUG0A11A
Number of Individuals Covered	624
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,843
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $159,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,843
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	712
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $56,226
Total amount of fees paid to insurance company	USD $88,319
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,226
Amount paid for insurance broker fees	88319
Additional information about fees paid to insurance broker	VOLUME INCENTIVES
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST, INC.

DENTAL CHOICE, INC. (National Association of Insurance Commissioners NAIC id number: 48127 )

Policy contract number

000DU57109

Policy instance

Insurance contract or identification number	000DU57109
Number of Individuals Covered	89
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $229
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 $229
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

DENTAL CHOICE, INC. (National Association of Insurance Commissioners NAIC id number: 48127 )

Policy contract number

000DU57109

Policy instance

Insurance contract or identification number	000DU57109
Number of Individuals Covered	89
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $229
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 $229
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	433
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $8,019
Total amount of fees paid to insurance company	USD $2,656
Vision 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 $10,675
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	411
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $12,818
Total amount of fees paid to insurance company	USD $2,363
Other welfare benefits provided	LIFE & AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $128,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,818
Amount paid for insurance broker fees	2363
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	433
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $8,019
Total amount of fees paid to insurance company	USD $2,656
Vision 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 $10,675
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	0
Insurance policy start date	2012-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $3,826
Total amount of fees paid to insurance company	USD $530,889
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,826
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC - LOUISVILLE

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

000DU5719

Policy instance

Insurance contract or identification number	000DU5719
Number of Individuals Covered	966
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $4,502
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 $4,502
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	576
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,729
Total amount of fees paid to insurance company	USD $2,764
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,729
Amount paid for insurance broker fees	2764
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	411
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $12,818
Total amount of fees paid to insurance company	USD $2,363
Other welfare benefits provided	LIFE & AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $128,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,818
Amount paid for insurance broker fees	2363
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AIIA

Policy instance

Insurance contract or identification number	GLUG0AIIA
Number of Individuals Covered	692
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,692
Total amount of fees paid to insurance company	USD $980
Other welfare benefits provided	LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $56,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,692
Amount paid for insurance broker fees	980
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AIIA

Policy instance

Insurance contract or identification number	GLUG0AIIA
Number of Individuals Covered	692
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,692
Total amount of fees paid to insurance company	USD $980
Other welfare benefits provided	LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $56,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,692
Amount paid for insurance broker fees	980
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

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

Policy contract number

0744133

Policy instance

Insurance contract or identification number	0744133
Number of Individuals Covered	535
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $48,731
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,731
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	576
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,729
Total amount of fees paid to insurance company	USD $2,764
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,729
Amount paid for insurance broker fees	2764
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

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

Policy contract number

0744133

Policy instance

Insurance contract or identification number	0744133
Number of Individuals Covered	535
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $48,731
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,731
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

000DU5719

Policy instance

Insurance contract or identification number	000DU5719
Number of Individuals Covered	966
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $4,502
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 $4,502
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	576
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,813
Total amount of fees paid to insurance company	USD $3,323
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,813
Amount paid for insurance broker fees	3323
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	576
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $5,813
Total amount of fees paid to insurance company	USD $3,323
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,813
Amount paid for insurance broker fees	3323
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI MIDWEST INC.

DENTAL CHOICE, INC. (National Association of Insurance Commissioners NAIC id number: 48127 )

Policy contract number

000DU5719

Policy instance

Insurance contract or identification number	000DU5719
Number of Individuals Covered	37
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $130
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

000DU5719

Policy instance

Insurance contract or identification number	000DU5719
Number of Individuals Covered	473
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $3,749
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	391
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $11,151
Other welfare benefits provided	LIFE & AD&D - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $111,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000/AIIA

Policy instance

Insurance contract or identification number	G000/AIIA
Number of Individuals Covered	575
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $5,797
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	575
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $5,676
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $142,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	497
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $91,443
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AIIA

Policy instance

Insurance contract or identification number	G000AIIA
Number of Individuals Covered	662
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $5,361
Other welfare benefits provided	LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $53,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677375G

Policy instance

Insurance contract or identification number	677375G
Number of Individuals Covered	645
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $6,251
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

FAE02044

Policy instance

Insurance contract or identification number	FAE02044
Number of Individuals Covered	651
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $4,788
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

535890

Policy instance

Insurance contract or identification number	535890
Number of Individuals Covered	493
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $77,201
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

FAE02044

Policy instance

Insurance contract or identification number	FAE02044
Number of Individuals Covered	651
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $4,612
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	THORNTONS LLC
Employer identification number (EIN):	351188206
NAIC Classification:	447100
NAIC Description:	Gasoline Stations, Gas