401k Plan data: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS plan

ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 401k Plan overview

Plan Name	ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS
Plan identification number	518

ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 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 Severance pay Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

CHILDREN'S HOSPITAL OF CHICAGO MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: CHILDREN'S HOSPITAL OF CHICAGO MEDICAL CENTER

Employer identification number (EIN): 363357004

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
518 2022-01-01 ALEX P. MILLER 2023-10-08
518 2021-01-01
518 2020-01-01 RON BLAUSTEIN 2021-09-22
518 2019-01-01
518 2018-01-01 JONI DUNCAN JONI DUNCAN 2019-07-22
518 2017-01-01 JONI DUNCAN JONI DUNCAN 2018-07-24
518 2016-01-01 JONI DUNCAN JONI DUNCAN 2017-07-25
518 2015-01-01 JONI DUNCAN JONI DUNCAN 2016-07-28
518 2015-01-01 JONI DUNCAN JONI DUNCAN 2016-07-28
518 2014-01-01 JONI DUNCAN JONI DUNCAN 2015-10-05
518 2013-01-01 JONI DUNCAN JONI DUNCAN 2014-10-07
518 2012-01-01 JONI DUNCAN JONI DUNCAN 2013-10-08
518 2011-01-01 PAULA M. NOBLE PAULA M. NOBLE 2012-10-12
518 2010-01-01 ROBERT POWELL ROBERT POWELL 2011-10-17
518 2009-01-01 BARBARA B. BOWMAN BARBARA B. BOWMAN 2010-10-11

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
518	2022-01-01	ALEX P. MILLER	2023-10-08
518	2021-01-01
518	2020-01-01	RON BLAUSTEIN	2021-09-22
518	2019-01-01
518	2018-01-01	JONI DUNCAN		JONI DUNCAN	2019-07-22
518	2017-01-01	JONI DUNCAN		JONI DUNCAN	2018-07-24
518	2016-01-01	JONI DUNCAN		JONI DUNCAN	2017-07-25
518	2015-01-01	JONI DUNCAN		JONI DUNCAN	2016-07-28
518	2015-01-01	JONI DUNCAN		JONI DUNCAN	2016-07-28
518	2014-01-01	JONI DUNCAN		JONI DUNCAN	2015-10-05
518	2013-01-01	JONI DUNCAN		JONI DUNCAN	2014-10-07
518	2012-01-01	JONI DUNCAN		JONI DUNCAN	2013-10-08
518	2011-01-01	PAULA M. NOBLE		PAULA M. NOBLE	2012-10-12
518	2010-01-01	ROBERT POWELL		ROBERT POWELL	2011-10-17
518	2009-01-01	BARBARA B. BOWMAN		BARBARA B. BOWMAN	2010-10-11

Plan Statistics for ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS

401k plan membership statisitcs for ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS

Measure Date Value
2022: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2022 401k membership
Total participants, beginning-of-year 2022-01-01 5,641
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 5,302
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 5,302
2021: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2021 401k membership
Total participants, beginning-of-year 2021-01-01 5,942
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 5,511
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 5,511
2020: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2020 401k membership
Total participants, beginning-of-year 2020-01-01 5,837
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 5,899
Number of retired or separated participants receiving benefits 2020-01-01 43
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 5,942
2019: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2019 401k membership
Total participants, beginning-of-year 2019-01-01 5,379
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 5,834
Number of retired or separated participants receiving benefits 2019-01-01 3
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 5,837
2018: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2018 401k membership
Total participants, beginning-of-year 2018-01-01 5,000
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 5,375
Total of all active and inactive participants 2018-01-01 5,375
2017: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2017 401k membership
Total participants, beginning-of-year 2017-01-01 4,800
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 5,000
Total of all active and inactive participants 2017-01-01 5,000
2016: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2016 401k membership
Total participants, beginning-of-year 2016-01-01 4,700
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 4,800
Total of all active and inactive participants 2016-01-01 4,800
2015: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 4,600
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 4,700
Total of all active and inactive participants 2015-01-01 4,700
2014: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 4,600
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 4,600
Total of all active and inactive participants 2014-01-01 4,600
2013: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 4,500
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 4,600
Total of all active and inactive participants 2013-01-01 4,600
2012: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2012 401k membership
Total participants, beginning-of-year 2012-01-01 4,205
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 4,500
Total of all active and inactive participants 2012-01-01 4,500
2011: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2011 401k membership
Total participants, beginning-of-year 2011-01-01 4,132
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 4,205
Total of all active and inactive participants 2011-01-01 4,205
2010: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2010 401k membership
Total participants, beginning-of-year 2010-01-01 3,704
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 4,116
Number of retired or separated participants receiving benefits 2010-01-01 16
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 4,132
Total participants 2010-01-01 4,132
2009: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2009 401k membership
Total participants, beginning-of-year 2009-01-01 3,669
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 3,687
Number of retired or separated participants receiving benefits 2009-01-01 17
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 3,704

Measure	Date	Value
2022: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2022 401k membership
Total participants, beginning-of-year	2022-01-01	5,641
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	5,302
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	5,302
2021: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2021 401k membership
Total participants, beginning-of-year	2021-01-01	5,942
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	5,511
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	5,511
2020: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2020 401k membership
Total participants, beginning-of-year	2020-01-01	5,837
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	5,899
Number of retired or separated participants receiving benefits	2020-01-01	43
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	5,942
2019: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2019 401k membership
Total participants, beginning-of-year	2019-01-01	5,379
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	5,834
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	5,837
2018: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2018 401k membership
Total participants, beginning-of-year	2018-01-01	5,000
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	5,375
Total of all active and inactive participants	2018-01-01	5,375
2017: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2017 401k membership
Total participants, beginning-of-year	2017-01-01	4,800
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	5,000
Total of all active and inactive participants	2017-01-01	5,000
2016: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	4,700
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	4,800
Total of all active and inactive participants	2016-01-01	4,800
2015: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	4,600
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	4,700
Total of all active and inactive participants	2015-01-01	4,700
2014: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	4,600
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	4,600
Total of all active and inactive participants	2014-01-01	4,600
2013: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	4,500
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	4,600
Total of all active and inactive participants	2013-01-01	4,600
2012: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	4,205
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	4,500
Total of all active and inactive participants	2012-01-01	4,500
2011: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	4,132
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	4,205
Total of all active and inactive participants	2011-01-01	4,205
2010: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2010 401k membership
Total participants, beginning-of-year	2010-01-01	3,704
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	4,116
Number of retired or separated participants receiving benefits	2010-01-01	16
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	4,132
Total participants	2010-01-01	4,132
2009: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	3,669
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	3,687
Number of retired or separated participants receiving benefits	2009-01-01	17
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	3,704

Form 5500 Responses for ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS

2022: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2021 form 5500 responses
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)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 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 benefit arrangement – Insurance	Yes
2019: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 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 benefit arrangement – Insurance	Yes
2018: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
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: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan 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: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 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: ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO INSURED WELFARE PLANS 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

Insurance Providers Used on plan

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	6417
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $26,940
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $538,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,940
Insurance broker organization code?	3

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

Policy contract number

0238578

Policy instance

Insurance contract or identification number	0238578
Number of Individuals Covered	952
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $43,197
Total amount of fees paid to insurance company	USD $3,717
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	CRITICAL ILLNESS
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 $286,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,197
Amount paid for insurance broker fees	3717
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION, MARKETING FEES
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	497
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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 $114,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0238579/849

Policy instance

Insurance contract or identification number	0238579/849
Number of Individuals Covered	1127
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $45,925
Total amount of fees paid to insurance company	USD $3,987
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	ACCIDENT, HOSPITAL
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 $307,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,925
Amount paid for insurance broker fees	3987
Additional information about fees paid to insurance broker	NON-MONETARY, SUPPLEMENTAL COMPENSATION, MARKETING FEES
Insurance broker organization code?	3

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	7197
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $156,037
Total amount of fees paid to insurance company	USD $97,037
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
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 $2,229,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $156,037
Amount paid for insurance broker fees	33018
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )

Policy contract number

GTA-101157

Policy instance

Insurance contract or identification number	GTA-101157
Number of Individuals Covered	6055
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
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	BUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADD-S09161

Policy instance

Insurance contract or identification number	ADD-S09161
Number of Individuals Covered	2082
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,003
Total amount of fees paid to insurance company	USD $3,060
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $71,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,003
Insurance broker organization code?	3
Amount paid for insurance broker fees	3060
Additional information about fees paid to insurance broker	FEES PAID

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	7142
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $171,888
Total amount of fees paid to insurance company	USD $111,585
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
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 $2,641,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $171,888
Amount paid for insurance broker fees	40019
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	493
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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 $121,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )

Policy contract number

GTA-101157

Policy instance

Insurance contract or identification number	GTA-101157
Number of Individuals Covered	6055
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
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	BUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	6117
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,890
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $465,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,890
Insurance broker organization code?	3

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

Policy contract number

ADD-S09161

Policy instance

Insurance contract or identification number	ADD-S09161
Number of Individuals Covered	2103
Insurance policy start date	2021-04-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,239
Total amount of fees paid to insurance company	USD $1,272
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $46,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,239
Insurance broker organization code?	3
Amount paid for insurance broker fees	1272
Additional information about fees paid to insurance broker	FEES PAID

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

Policy contract number

0167933

Policy instance

Insurance contract or identification number	0167933
Number of Individuals Covered	1076
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $64,623
Total amount of fees paid to insurance company	USD $6,800
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	ACCIDENT, HOSPITAL
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 $303,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,623
Amount paid for insurance broker fees	6800
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0165505

Policy instance

Insurance contract or identification number	0165505
Number of Individuals Covered	873
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $55,916
Total amount of fees paid to insurance company	USD $5,914
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	CRITICAL ILLNESS
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 $265,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,916
Amount paid for insurance broker fees	5914
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2182
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-31
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	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 $23,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	7119
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $199,767
Total amount of fees paid to insurance company	USD $129,555
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
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 $2,667,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $199,767
Amount paid for insurance broker fees	39467
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

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

Policy contract number

0165505

Policy instance

Insurance contract or identification number	0165505
Number of Individuals Covered	853
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $44,481
Total amount of fees paid to insurance company	USD $3,324
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	CRITICAL ILLNESS
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 $244,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,481
Amount paid for insurance broker fees	3106
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GTA-101157

Policy instance

Insurance contract or identification number	GTA-101157
Number of Individuals Covered	6020
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $6,216
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	BUSINESS TRAVEL ACCIDENT
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 $31,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,216
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	563
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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 $135,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0167933

Policy instance

Insurance contract or identification number	0167933
Number of Individuals Covered	1067
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $52,946
Total amount of fees paid to insurance company	USD $3,962
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	ACCIDENT
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 $141,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,946
Amount paid for insurance broker fees	3700
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	3284
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $22,905
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $458,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,905
Insurance broker organization code?	3

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2193
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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	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 $97,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0167933

Policy instance

Insurance contract or identification number	0167933
Number of Individuals Covered	2665
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $48,987
Total amount of fees paid to insurance company	USD $3,235
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	ACCIDENT
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 $251,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,031
Amount paid for insurance broker fees	1887
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION, MARKETING FEES
Insurance broker organization code?	3

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

Policy contract number

ETB-119285

Policy instance

Insurance contract or identification number	ETB-119285
Number of Individuals Covered	4785
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
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	BUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0165505

Policy instance

Insurance contract or identification number	0165505
Number of Individuals Covered	1136
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $40,110
Total amount of fees paid to insurance company	USD $2,636
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	CRITICAL ILLNESS
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 $208,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,898
Amount paid for insurance broker fees	1395
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION, MARKETING FEES
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	606
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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 $152,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	7448
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $162,513
Total amount of fees paid to insurance company	USD $95,338
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
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 $2,321,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $162,513
Amount paid for insurance broker fees	43267
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	3268
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $21,912
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $475,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,912
Insurance broker organization code?	3

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2313
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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	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 $98,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	5375
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $216,333
Total amount of fees paid to insurance company	USD $109,661
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,090,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $216,333
Amount paid for insurance broker fees	28462
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	5276
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $20,016
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $344,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,016
Insurance broker organization code?	3

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2285
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $96,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	599
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB-119285

Policy instance

Insurance contract or identification number	ETB-119285
Number of Individuals Covered	5375
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BTA
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

167933

Policy instance

Insurance contract or identification number	167933
Number of Individuals Covered	566
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $42,437
Total amount of fees paid to insurance company	USD $1,475
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,469
Amount paid for insurance broker fees	278
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	3369
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

165505

Policy instance

Insurance contract or identification number	165505
Number of Individuals Covered	628
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $33,116
Total amount of fees paid to insurance company	USD $1,266
Other welfare benefits provided	CII
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,177
Amount paid for insurance broker fees	222
Additional information about fees paid to insurance broker	NON-MONETARY & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

167933

Policy instance

Insurance contract or identification number	167933
Number of Individuals Covered	285
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $28,101
Total amount of fees paid to insurance company	USD $12
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,101
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTEGRO USA INC DBA INTEGRO INS BKR

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

Policy contract number

165505

Policy instance

Insurance contract or identification number	165505
Number of Individuals Covered	445
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $23,909
Total amount of fees paid to insurance company	USD $12
Other welfare benefits provided	CII
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,909
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTEGRO USA INC DBA INTEGRO INS BKR

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

Policy contract number

ETB-119285

Policy instance

Insurance contract or identification number	ETB-119285
Number of Individuals Covered	5000
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $5,636
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BTA
Welfare Benefit Premiums Paid to Carrier	USD $28,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,636
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	527
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2278
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $97,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0904872

Policy instance

Insurance contract or identification number	0904872
Number of Individuals Covered	2551
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16,206
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $380,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,206
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4735
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $118,194
Total amount of fees paid to insurance company	USD $89,593
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,778,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118,194
Amount paid for insurance broker fees	34131
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4604
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $117,005
Total amount of fees paid to insurance company	USD $128,242
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,883,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $117,005
Amount paid for insurance broker fees	46782
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2244
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $94,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	445
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )

Policy contract number

AH-0019-0108-00

Policy instance

Insurance contract or identification number	AH-0019-0108-00
Number of Individuals Covered	4700
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,260
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,260
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING, INC.

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

Policy contract number

5810

Policy instance

Insurance contract or identification number	5810
Number of Individuals Covered	2170
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,815
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $196,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,815
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4640
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $114,715
Total amount of fees paid to insurance company	USD $158,579
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,674,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114,715
Amount paid for insurance broker fees	53373
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

211868/5810

Policy instance

Insurance contract or identification number	211868/5810
Number of Individuals Covered	2191
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,812
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,812
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2161
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $81,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	422
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )

Policy contract number

AH-0019-0108-00

Policy instance

Insurance contract or identification number	AH-0019-0108-00
Number of Individuals Covered	4600
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,260
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,260
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING, INC.

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

Policy contract number

5810

Policy instance

Insurance contract or identification number	5810
Number of Individuals Covered	2215
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,954
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $168,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,954
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009240

Policy instance

Insurance contract or identification number	GTU0009240
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2007
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $85,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	379
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )

Policy contract number

AH-0019-0108-00

Policy instance

Insurance contract or identification number	AH-0019-0108-00
Number of Individuals Covered	4600
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,130
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,130
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING, INC.

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

Policy contract number

211868

Policy instance

Insurance contract or identification number	211868
Number of Individuals Covered	2005
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,091
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $261,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,091
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4482
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $108,606
Total amount of fees paid to insurance company	USD $100,626
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,865,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108,606
Amount paid for insurance broker fees	55146
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	ALEXANDER BENEFITS CONSULTING LLC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
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 $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	2007
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $80,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009240

Policy instance

Insurance contract or identification number	GTU0009240
Number of Individuals Covered	4500
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

211868

Policy instance

Insurance contract or identification number	211868
Number of Individuals Covered	1582
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,781
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $215,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,781
Insurance broker organization code?	3
Insurance broker name	CHILD HEALTH CORP OF AMERICA

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4222
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $115,499
Total amount of fees paid to insurance company	USD $114,100
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,615,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $115,499
Amount paid for insurance broker fees	49495
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	ALEXANDER BENEFITS CONSULTING LLC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	434
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009242

Policy instance

Insurance contract or identification number	GTU0009242
Number of Individuals Covered	1951
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $78,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009240

Policy instance

Insurance contract or identification number	GTU0009240
Number of Individuals Covered	3210
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $30,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	4205
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $83,387
Total amount of fees paid to insurance company	USD $103,016
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,406,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

211868

Policy instance

Insurance contract or identification number	211868
Number of Individuals Covered	1377
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,127
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU 0009242

Policy instance

Insurance contract or identification number	GTU 0009242
Number of Individuals Covered	743
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
Welfare Benefit Premiums Paid to Carrier	USD $74,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU0009240

Policy instance

Insurance contract or identification number	GTU0009240
Number of Individuals Covered	4116
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
Welfare Benefit Premiums Paid to Carrier	USD $31,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774GLT

Policy instance

Insurance contract or identification number	674774GLT
Number of Individuals Covered	4116
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $101,576
Total amount of fees paid to insurance company	USD $36,363
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $832,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

211868

Policy instance

Insurance contract or identification number	211868
Number of Individuals Covered	1359
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,112
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $142,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10126

Policy instance

Insurance contract or identification number	10126
Number of Individuals Covered	441
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674774G

Policy instance

Insurance contract or identification number	674774G
Number of Individuals Covered	3727
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $42,616
Total amount of fees paid to insurance company	USD $7,719
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $603,123
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

H32692 H32693

Policy instance

Insurance contract or identification number	H32692 H32693
Number of Individuals Covered	2664
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $12,081
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CHILDREN'S HOSPITAL OF CHICAGO MEDICAL CENTER
Employer identification number (EIN):	363357004
NAIC Classification:	622000
NAIC Description:	Hospitals