PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN
Plan identification number	501

PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME has sponsored the creation of one or more 401k plans.

Company Name:	REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME
Employer identification number (EIN):	362382853
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Additional information about REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME

Jurisdiction of Incorporation:	Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number:	900652

More information about REST HAVEN ILLIANA CHRISTIAN CONVALESCENT HOME

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-05-01	BARRY VANDERGENUGTEN	2024-02-15
501	2021-05-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	BARRY VANDERGENUGTEN
501	2017-01-01	BARRY VANDERGENUGTEN
501	2016-01-01	BARRY VANDERGENUGTEN
501	2015-01-01	BARRY VANDERGENUGTEN
501	2014-01-01	BARRY VANDERGENUGTEN
501	2013-01-01	BARRY VANDERGENUGTEN
501	2012-01-01	BARRY VANDERGENUGTEN		BARRY VANDERGENUGTEN	2013-07-08
501	2011-01-01	BARRY VANDERGENUGTEN		BARRY VANDERGENUGTEN	2012-06-12
501	2010-01-01	BARRY VANDERGENUGTEN
501	2009-01-01	BARRY VANDERGENUGTEN
501	2008-01-01	BARRY VANDERGENUGTEN
501	2007-01-01	BARRY VANDERGENUGTEN
501	2006-01-01	BARRY VANDERGENUGTEN
501	2005-01-01	BARRY VANDERGENUGTEN
501	2004-01-01	BARRY VANDERGENUGTEN
501	2003-01-01	BARRY VANDERGENUGTEN

Plan Statistics for PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN

Measure	Date	Value
2022: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	745
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	639
Number of retired or separated participants receiving benefits	2022-05-01	0
Number of other retired or separated participants entitled to future benefits	2022-05-01	0
Total of all active and inactive participants	2022-05-01	639
Number of employers contributing to the scheme	2022-05-01	0
2021: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-05-01	811
Total number of active participants reported on line 7a of the Form 5500	2021-05-01	734
Number of retired or separated participants receiving benefits	2021-05-01	11
Number of other retired or separated participants entitled to future benefits	2021-05-01	0
Total of all active and inactive participants	2021-05-01	745
Total participants, beginning-of-year	2021-01-01	802
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	807
Number of retired or separated participants receiving benefits	2021-01-01	4
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	811
2020: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	841
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	800
Number of retired or separated participants receiving benefits	2020-01-01	2
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	802
2019: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	840
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	835
Number of retired or separated participants receiving benefits	2019-01-01	6
Total of all active and inactive participants	2019-01-01	841
2018: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	953
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	840
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	840
2017: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	936
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,358
Number of retired or separated participants receiving benefits	2017-01-01	3
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,361
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
2016: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	362
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	936
Number of retired or separated participants receiving benefits	2016-01-01	3
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	939
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
2015: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	341
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	362
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	362
2014: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	322
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	340
Number of retired or separated participants receiving benefits	2014-01-01	2
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	342
2013: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	430
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	323
Number of retired or separated participants receiving benefits	2013-01-01	6
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	329
2012: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	391
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	430
Number of retired or separated participants receiving benefits	2012-01-01	3
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	433
2011: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	374
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	391
Number of retired or separated participants receiving benefits	2011-01-01	3
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	394
2010: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	391
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	379
Number of retired or separated participants receiving benefits	2010-01-01	22
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	401
2009: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	343
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	391
Number of retired or separated participants receiving benefits	2009-01-01	33
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	424
2008: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	336
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	343
Number of retired or separated participants receiving benefits	2008-01-01	31
Number of other retired or separated participants entitled to future benefits	2008-01-01	0
Total of all active and inactive participants	2008-01-01	374
2007: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	346
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	336
Number of retired or separated participants receiving benefits	2007-01-01	26
Number of other retired or separated participants entitled to future benefits	2007-01-01	0
Total of all active and inactive participants	2007-01-01	362
2006: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2006 401k membership
Total participants, beginning-of-year	2006-01-01	329
Total number of active participants reported on line 7a of the Form 5500	2006-01-01	346
Number of retired or separated participants receiving benefits	2006-01-01	39
Number of other retired or separated participants entitled to future benefits	2006-01-01	0
Total of all active and inactive participants	2006-01-01	385
2005: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2005 401k membership
Total participants, beginning-of-year	2005-01-01	413
Total number of active participants reported on line 7a of the Form 5500	2005-01-01	329
Number of retired or separated participants receiving benefits	2005-01-01	21
Number of other retired or separated participants entitled to future benefits	2005-01-01	0
Total of all active and inactive participants	2005-01-01	350
2004: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2004 401k membership
Total participants, beginning-of-year	2004-01-01	450
Total number of active participants reported on line 7a of the Form 5500	2004-01-01	413
Number of retired or separated participants receiving benefits	2004-01-01	40
Number of other retired or separated participants entitled to future benefits	2004-01-01	0
Total of all active and inactive participants	2004-01-01	453
2003: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2003 401k membership
Total participants, beginning-of-year	2003-01-01	452
Total number of active participants reported on line 7a of the Form 5500	2003-01-01	450
Number of retired or separated participants receiving benefits	2003-01-01	8
Number of other retired or separated participants entitled to future benefits	2003-01-01	0
Total of all active and inactive participants	2003-01-01	458

Form 5500 Responses for PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN

2022: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-05-01	Type of plan entity	Single employer plan
2021-05-01	Submission has been amended	No
2021-05-01	This submission is the final filing	No
2021-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-05-01	Plan is a collectively bargained plan	No
2021-05-01	Plan funding arrangement – Insurance	Yes
2021-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-05-01	Plan benefit arrangement – Insurance	Yes
2021-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
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: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2008: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Submission has been amended	No
2008-01-01	This submission is the final filing	No
2008-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-01-01	Plan is a collectively bargained plan	No
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2007: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	No
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2006: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	Submission has been amended	No
2006-01-01	This submission is the final filing	No
2006-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-01-01	Plan is a collectively bargained plan	No
2006-01-01	Plan funding arrangement – Insurance	Yes
2006-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2006-01-01	Plan benefit arrangement – Insurance	Yes
2006-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2005: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	Submission has been amended	No
2005-01-01	This submission is the final filing	No
2005-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-01-01	Plan is a collectively bargained plan	No
2005-01-01	Plan funding arrangement – Insurance	Yes
2005-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2005-01-01	Plan benefit arrangement – Insurance	Yes
2005-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2004: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2004 form 5500 responses
2004-01-01	Type of plan entity	Single employer plan
2004-01-01	Submission has been amended	No
2004-01-01	This submission is the final filing	No
2004-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-01-01	Plan is a collectively bargained plan	No
2004-01-01	Plan funding arrangement – Insurance	Yes
2004-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2004-01-01	Plan benefit arrangement – Insurance	Yes
2004-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2003: PROVIDENCE LIFE SERVICES EMPLOYEE BENEFIT PLAN 2003 form 5500 responses
2003-01-01	Type of plan entity	Single employer plan
2003-01-01	First time form 5500 has been submitted	Yes
2003-01-01	Submission has been amended	No
2003-01-01	This submission is the final filing	No
2003-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2003-01-01	Plan is a collectively bargained plan	No
2003-01-01	Plan funding arrangement – Insurance	Yes
2003-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2003-01-01	Plan benefit arrangement – Insurance	Yes
2003-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	2
Insurance contract or identification number F195399 Number of Individuals Covered 81 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $618 Total amount of fees paid to insurance company USD $355 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $6,177 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $618 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5969678
Policy instance	8
Insurance contract or identification number 5969678 Number of Individuals Covered 639 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $37,595 Total amount of fees paid to insurance company USD $299 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS,ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $280,835 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,790 Amount paid for insurance broker fees 194 Additional information about fees paid to insurance broker MARKETING FEES, NON-MONETARY COMPENSATION Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	95399
Policy instance	1
Insurance contract or identification number 95399 Number of Individuals Covered 494 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $91,150 Total amount of fees paid to insurance company USD $5,334 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $486,560 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $91,150 Amount paid for insurance broker fees 5334 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	3
Insurance contract or identification number 379336 Number of Individuals Covered 305 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $13,147 Total amount of fees paid to insurance company USD $5,215 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $214,383 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,766 Amount paid for insurance broker fees 5215 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AK6Y
Policy instance	4
Insurance contract or identification number GLUG0AK6Y Number of Individuals Covered 15 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $44 Total amount of fees paid to insurance company USD $13 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $439 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44 Amount paid for insurance broker fees 13 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number	774972
Policy instance	5
Insurance contract or identification number 774972 Number of Individuals Covered 30 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	6
Insurance contract or identification number 00 Number of Individuals Covered 9 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $2,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HY3883
Policy instance	7
Insurance contract or identification number HY3883 Number of Individuals Covered 285 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $3,350 Total amount of fees paid to insurance company USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided TELEHEALTH Welfare Benefit Premiums Paid to Carrier USD $22,332 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,350 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	1
Insurance contract or identification number 095399 Number of Individuals Covered 669 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $121,086 Total amount of fees paid to insurance company USD $5,684 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $527,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $121,086 Amount paid for insurance broker fees 5684 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5969678
Policy instance	3
Insurance contract or identification number 5969678 Number of Individuals Covered 734 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $39,518 Total amount of fees paid to insurance company USD $2,491 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $317,627 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,518 Amount paid for insurance broker fees 2491 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	4
Insurance contract or identification number F195399 Number of Individuals Covered 348 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $797 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $7,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $797 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	5
Insurance contract or identification number 00379336 Number of Individuals Covered 388 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $15,298 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $254,430 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,298 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AK6Y
Policy instance	6
Insurance contract or identification number GLUG0AK6Y Number of Individuals Covered 13 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $56 Total amount of fees paid to insurance company USD $24 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $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 $56 Amount paid for insurance broker fees 24 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number	774972
Policy instance	2
Insurance contract or identification number 774972 Number of Individuals Covered 21 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $5,067 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $168,902 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,067 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5969678
Policy instance	1
Insurance contract or identification number 5969678 Number of Individuals Covered 807 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $13,485 Total amount of fees paid to insurance company USD $3,362 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $279,989 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,485 Amount paid for insurance broker fees 3362 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	2
Insurance contract or identification number 00379336 Number of Individuals Covered 345 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $3,852 Total amount of fees paid to insurance company USD $855 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $64,194 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,852 Amount paid for insurance broker fees 855 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	3
Insurance contract or identification number F195399 Number of Individuals Covered 84 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $255 Total amount of fees paid to insurance company USD $522 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $2,551 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $255 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	4
Insurance contract or identification number 095399 Number of Individuals Covered 738 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $53,754 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $152,848 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,754 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 374 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $795 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $8,119 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $795 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400002000 01420
Policy instance	2
Insurance contract or identification number 400002000 01420 Number of Individuals Covered 114 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $10,559 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $70,393 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,559 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022090 00000
Policy instance	3
Insurance contract or identification number 10022090 00000 Number of Individuals Covered 633 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $8,621 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $86,213 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,621 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	4
Insurance contract or identification number 00379336 Number of Individuals Covered 335 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $10,887 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $181,455 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,887 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 03049
Policy instance	5
Insurance contract or identification number 400001000 03049 Number of Individuals Covered 132 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $5,914 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $39,427 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,914 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	6
Insurance contract or identification number 095399 Number of Individuals Covered 740 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $164,118 Total amount of fees paid to insurance company USD $6,855 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $458,028 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $164,118 Amount paid for insurance broker fees 6855 Additional information about fees paid to insurance broker SPECIAL PROGRAMS FEES Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022091 00000
Policy instance	7
Insurance contract or identification number 10022091 00000 Number of Individuals Covered 633 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $14,561 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $145,614 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,561 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	6
Insurance contract or identification number 095399 Number of Individuals Covered 755 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $183,226 Total amount of fees paid to insurance company USD $4,270 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $408,547 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-12,900 Amount paid for insurance broker fees 4270 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 03049
Policy instance	5
Insurance contract or identification number 400001000 03049 Number of Individuals Covered 130 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $5,520 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $36,796 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,520 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	4
Insurance contract or identification number 00379336 Number of Individuals Covered 326 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $13,780 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $229,663 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,780 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022090 00000
Policy instance	3
Insurance contract or identification number 10022090 00000 Number of Individuals Covered 611 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $7,835 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $78,347 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,835 Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 365 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $812 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $8,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $812 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400002000 01420
Policy instance	2
Insurance contract or identification number 400002000 01420 Number of Individuals Covered 118 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $7,969 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $53,128 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,969 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022091 00000
Policy instance	7
Insurance contract or identification number 10022091 00000 Number of Individuals Covered 611 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $11,985 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $119,848 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,985 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AK6Y
Policy instance	1
Insurance contract or identification number GLUG0AK6Y Number of Individuals Covered 22 Insurance policy start date 2018-12-01 Insurance policy end date 2019-12-01 Total amount of commissions paid to insurance broker USD $82 Total amount of fees paid to insurance company USD $126 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $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 $82 Amount paid for insurance broker fees 126 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	5
Insurance contract or identification number 00379336 Number of Individuals Covered 326 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $13,780 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $229,663 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,780 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 03049
Policy instance	6
Insurance contract or identification number 400001000 03049 Number of Individuals Covered 130 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $5,520 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $36,796 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,520 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022091 00000
Policy instance	8
Insurance contract or identification number 10022091 00000 Number of Individuals Covered 611 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $11,985 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $119,848 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,985 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	7
Insurance contract or identification number 095399 Number of Individuals Covered 755 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $183,226 Total amount of fees paid to insurance company USD $4,270 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $408,547 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-12,900 Amount paid for insurance broker fees 4270 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022090 00000
Policy instance	4
Insurance contract or identification number 10022090 00000 Number of Individuals Covered 611 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $7,835 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $78,347 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,835 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400002000 01420
Policy instance	3
Insurance contract or identification number 400002000 01420 Number of Individuals Covered 118 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $7,969 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $53,128 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,969 Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	2
Insurance contract or identification number F195399 Number of Individuals Covered 365 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $812 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $8,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $812 Insurance broker organization code? 3
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	8
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 840 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $12,550 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	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 417 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $814 Total amount of fees paid to insurance company USD $265 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $8,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $583 Insurance broker organization code? 3 Amount paid for insurance broker fees 265 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022091 00000
Policy instance	7
Insurance contract or identification number 10022091 00000 Number of Individuals Covered 763 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $10,951 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $109,509 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,951 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	6
Insurance contract or identification number 095399 Number of Individuals Covered 835 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $155,670 Total amount of fees paid to insurance company USD $3,870 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $358,206 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $155,670 Amount paid for insurance broker fees 3870 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 03049
Policy instance	5
Insurance contract or identification number 400001000 03049 Number of Individuals Covered 93 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $4,873 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $32,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,873 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00379336
Policy instance	4
Insurance contract or identification number 00379336 Number of Individuals Covered 372 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $12,871 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $214,510 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,871 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022090 00000
Policy instance	3
Insurance contract or identification number 10022090 00000 Number of Individuals Covered 763 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $8,966 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $89,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,966 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400002000 01420
Policy instance	2
Insurance contract or identification number 400002000 01420 Number of Individuals Covered 92 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $7,607 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $50,714 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,607 Insurance broker organization code? 3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	3
Insurance contract or identification number F195399 Number of Individuals Covered 402 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $674 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 $8,219 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $674 Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	4
Insurance contract or identification number 379336 Number of Individuals Covered 356 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $9,724 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 Welfare Benefit Premiums Paid to Carrier USD $162,070 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,724 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 091, 090
Policy instance	5
Insurance contract or identification number 10022 091, 090 Number of Individuals Covered 723 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $15,954 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 Yes 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 $159,535 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,954 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003049
Policy instance	6
Insurance contract or identification number 40000100003049 Number of Individuals Covered 87 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $4,335 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $28,896 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,335 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	7
Insurance contract or identification number 40000200001420 Number of Individuals Covered 78 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $5,605 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 $37,365 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,605 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AK6Y
Policy instance	8
Insurance contract or identification number G000AK6Y Number of Individuals Covered 97 Insurance policy start date 2016-12-01 Insurance policy end date 2017-11-30 Total amount of commissions paid to insurance broker USD $342 Total amount of fees paid to insurance company USD $175 Are there contracts with allocated funds for individual policies? 0 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 $3,414 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $342 Amount paid for insurance broker fees 175 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	2
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 548 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $12,600 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	095399
Policy instance	1
Insurance contract or identification number 095399 Number of Individuals Covered 790 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $217,294 Total amount of fees paid to insurance company USD $3,610 Are there contracts with allocated funds for individual policies? 0 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 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 Welfare Benefit Premiums Paid to Carrier USD $298,151 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $217,294 Amount paid for insurance broker fees 3610 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AK6Y
Policy instance	7
Insurance contract or identification number G000AK6Y Number of Individuals Covered 97 Insurance policy start date 2016-12-01 Insurance policy end date 2017-11-30 Total amount of commissions paid to insurance broker USD $342 Total amount of fees paid to insurance company USD $175 Are there contracts with allocated funds for individual policies? 0 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 $3,414 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $342 Amount paid for insurance broker fees 175 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	1
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 548 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $12,600 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	F195399
Policy instance	2
Insurance contract or identification number F195399 Number of Individuals Covered 402 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $674 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 $8,219 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $674 Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	3
Insurance contract or identification number 379336 Number of Individuals Covered 356 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $9,724 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 Welfare Benefit Premiums Paid to Carrier USD $162,070 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,724 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 091, 090
Policy instance	4
Insurance contract or identification number 10022 091, 090 Number of Individuals Covered 723 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $15,954 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 Yes 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 $159,535 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,954 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003049
Policy instance	5
Insurance contract or identification number 40000100003049 Number of Individuals Covered 87 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $4,335 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $28,896 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,335 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	6
Insurance contract or identification number 40000200001420 Number of Individuals Covered 78 Insurance policy start date 2016-05-01 Insurance policy end date 2017-04-30 Total amount of commissions paid to insurance broker USD $5,605 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 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 $37,365 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,605 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	4
Insurance contract or identification number 379336 Number of Individuals Covered 329 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $8,528 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 Welfare Benefit Premiums Paid to Carrier USD $142,139 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,528 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	7
Insurance contract or identification number 40000200001420 Number of Individuals Covered 58 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,749 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 $31,656 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,749 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	6
Insurance contract or identification number 4000100003049 Number of Individuals Covered 71 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,882 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $25,872 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,882 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 091, 090
Policy instance	5
Insurance contract or identification number 10022 091, 090 Number of Individuals Covered 632 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $18,169 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 Yes 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 $181,689 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,169 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	2
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 362 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $8,100 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	1
Insurance contract or identification number P H B 95404 Number of Individuals Covered 660 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $136,614 Total amount of fees paid to insurance company USD $3,190 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 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 $136,614 Amount paid for insurance broker fees 3190 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	3
Insurance contract or identification number F195399 Number of Individuals Covered 378 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $684 Total amount of fees paid to insurance company USD $402 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 $7,025 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $684 Amount paid for insurance broker fees 402 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AK6Y
Policy instance	8
Insurance contract or identification number G000AK6Y Number of Individuals Covered 105 Insurance policy start date 2014-12-01 Insurance policy end date 2015-11-30 Total amount of commissions paid to insurance broker USD $302 Total amount of fees paid to insurance company USD $101 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 $3,024 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $302 Amount paid for insurance broker fees 101 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	7
Insurance contract or identification number P H B 95404 Number of Individuals Covered 614 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $152,487 Total amount of fees paid to insurance company USD $3,870 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 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 $152,487 Amount paid for insurance broker fees 3870 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 335 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $573 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 $7,065 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $573 Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	2
Insurance contract or identification number 379336 Number of Individuals Covered 319 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $10,437 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 Welfare Benefit Premiums Paid to Carrier USD $173,956 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,437 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	3
Insurance contract or identification number 4000100003049 Number of Individuals Covered 72 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $3,886 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $25,904 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,886 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	6
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 23 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $8,470 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 090 091
Policy instance	5
Insurance contract or identification number 10022 090 091 Number of Individuals Covered 611 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $19,556 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 Yes 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 $195,565 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,556 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AK6Y
Policy instance	8
Insurance contract or identification number G000AK6Y Number of Individuals Covered 112 Insurance policy start date 2013-12-01 Insurance policy end date 2014-11-30 Total amount of commissions paid to insurance broker USD $399 Total amount of fees paid to insurance company USD $62 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 $3,993 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $399 Amount paid for insurance broker fees 62 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	4
Insurance contract or identification number 40000200001420 Number of Individuals Covered 64 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $5,403 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 $36,019 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,403 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	085038
Policy instance	8
Insurance contract or identification number 085038 Number of Individuals Covered 18 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $95 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 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 $795 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $95 Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	7
Insurance contract or identification number P H B 95404 Number of Individuals Covered 755 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $189,251 Total amount of fees paid to insurance company USD $6,649 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 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 $189,251 Amount paid for insurance broker fees 6649 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	6
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 23 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $8,470 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	4
Insurance contract or identification number 40000200001420 Number of Individuals Covered 89 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $6,609 Total amount of fees paid to insurance company USD $869 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 $44,059 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,609 Amount paid for insurance broker fees 869 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	3
Insurance contract or identification number 4000100003049 Number of Individuals Covered 82 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $4,174 Total amount of fees paid to insurance company USD $565 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $27,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,174 Amount paid for insurance broker fees 565 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	2
Insurance contract or identification number 379336 Number of Individuals Covered 310 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $8,096 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 Welfare Benefit Premiums Paid to Carrier USD $146,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,096 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 090 091
Policy instance	5
Insurance contract or identification number 10022 090 091 Number of Individuals Covered 737 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $19,402 Total amount of fees paid to insurance company USD $5,295 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 Yes 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 $194,020 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,402 Amount paid for insurance broker fees 5295 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 68 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $726 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 $8,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $726 Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	085038
Policy instance	8
Insurance contract or identification number 085038 Number of Individuals Covered 20 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $93 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 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 $773 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $93 Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP, INC.
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	6
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 29 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $16,905 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 090 091
Policy instance	5
Insurance contract or identification number 10022 090 091 Number of Individuals Covered 697 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $25,100 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 Yes 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 $250,995 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,100 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	4
Insurance contract or identification number 40000200001420 Number of Individuals Covered 104 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $6,186 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 $41,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,186 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	2
Insurance contract or identification number 379336 Number of Individuals Covered 401 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $4,884 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 Welfare Benefit Premiums Paid to Carrier USD $148,466 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,884 Insurance broker organization code? 3 Insurance broker name THE VAN DYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	3
Insurance contract or identification number 4000100003049 Number of Individuals Covered 76 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $3,931 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $26,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,931 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	7
Insurance contract or identification number P H B 95404 Number of Individuals Covered 729 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $122,804 Total amount of fees paid to insurance company USD $7,149 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 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 $122,804 Amount paid for insurance broker fees 7149 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F195399
Policy instance	1
Insurance contract or identification number F195399 Number of Individuals Covered 500 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $852 Total amount of fees paid to insurance company USD $372 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 $10,140 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $852 Amount paid for insurance broker fees 372 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	7
Insurance contract or identification number 40000200001420 Number of Individuals Covered 102 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $6,229 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 $41,530 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	1
Insurance contract or identification number P H B 95404 Number of Individuals Covered 694 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $145,425 Total amount of fees paid to insurance company USD $10,555 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 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
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	2
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 29 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $16,905 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	F195399
Policy instance	3
Insurance contract or identification number F195399 Number of Individuals Covered 385 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $970 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 $11,976 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	085038
Policy instance	8
Insurance contract or identification number 085038 Number of Individuals Covered 19 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $96 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 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 $824 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	6
Insurance contract or identification number 4000100003049 Number of Individuals Covered 73 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $4,101 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $27,331 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 090 091
Policy instance	5
Insurance contract or identification number 10022 090 091 Number of Individuals Covered 688 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $23,972 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 Yes 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 $239,724 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	4
Insurance contract or identification number 379336 Number of Individuals Covered 363 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 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 Welfare Benefit Premiums Paid to Carrier USD $163,196 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	085038
Policy instance	8
Insurance contract or identification number 085038 Number of Individuals Covered 18 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $82 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 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 $938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $82 Insurance broker organization code? 3 Insurance broker name ADVANTAGE BENEFITS GROUP, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200001420
Policy instance	7
Insurance contract or identification number 40000200001420 Number of Individuals Covered 99 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $6,230 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 $41,531 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,230 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
CHICAGO CHRISTIAN COUNSELING CENTER (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	PROVIDENCE
Policy instance	2
Insurance contract or identification number PROVIDENCE Number of Individuals Covered 52 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $19,855 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	4000100003049
Policy instance	6
Insurance contract or identification number 4000100003049 Number of Individuals Covered 71 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $3,903 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOL LIFE PRODUCTS 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 $26,009 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,903 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10022 090 091
Policy instance	5
Insurance contract or identification number 10022 090 091 Number of Individuals Covered 660 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $25,253 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 Yes 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 $252,528 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,253 Insurance broker organization code? 3 Insurance broker name THE VANDYKE GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	379336
Policy instance	4
Insurance contract or identification number 379336 Number of Individuals Covered 334 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 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 Welfare Benefit Premiums Paid to Carrier USD $153,174 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	F195399
Policy instance	3
Insurance contract or identification number F195399 Number of Individuals Covered 387 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $984 Total amount of fees paid to insurance company USD $96 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 Yes 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 $11,872 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $984 Amount paid for insurance broker fees 96 Additional information about fees paid to insurance broker ADD'L COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number	P H B 95404
Policy instance	1
Insurance contract or identification number P H B 95404 Number of Individuals Covered 657 Insurance policy start date 2009-05-01 Insurance policy end date 2010-04-30 Total amount of commissions paid to insurance broker USD $122,302 Total amount of fees paid to insurance company USD $5,068 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 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 $122,302 Amount paid for insurance broker fees 5068 Additional information about fees paid to insurance broker SPECIAL PROGRAMS Insurance broker organization code? 3 Insurance broker name ASSURANCE AGENCY