401k Plan data: BLACK HORSE CARRIERS, INC. WELFARE PLAN plan

BLACK HORSE CARRIERS, INC. WELFARE PLAN 401k Plan overview

Plan Name	BLACK HORSE CARRIERS, INC. WELFARE PLAN
Plan identification number	501

BLACK HORSE CARRIERS, INC. WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

PENSKE TRUCK LEASING CO., L.P. has sponsored the creation of one or more 401k plans.

Company Name: PENSKE TRUCK LEASING CO., L.P.

Employer identification number (EIN): 364284078

NAIC Classification: 484110
NAIC Description: General Freight Trucking, Local

Additional information about PENSKE TRUCK LEASING CO., L.P.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2012-05-14

Company Identification Number: 0801597800

Legal Registered Office Address: 1000 E WARRENVILLE RD STE 200

NAPERVILLE
United States of America (USA)
60563

More information about PENSKE TRUCK LEASING CO., L.P.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLACK HORSE CARRIERS, INC. WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 MARIO MATESIC MARIO MATESIC
501 2021-01-01 MARIO MATESIC 2022-10-15 MARIO MATESIC 2022-10-15
501 2020-01-01 GEOFF GIBSON GEOFF GIBSON
501 2019-01-01 KEN THOMSON 2020-07-23 KEN THOMSON 2020-07-23
501 2018-01-01 KEN THOMSON 2019-10-09 KEN THOMSON 2019-10-09
501 2017-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 TERESA NIEDERT
501 2011-01-01 TERESA NIEDERT
501 2010-01-01 TERESA NIEDERT
501 2009-01-01 TERRI NIEDERT

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	MARIO MATESIC		MARIO MATESIC
501	2021-01-01	MARIO MATESIC	2022-10-15	MARIO MATESIC	2022-10-15
501	2020-01-01	GEOFF GIBSON		GEOFF GIBSON
501	2019-01-01	KEN THOMSON	2020-07-23	KEN THOMSON	2020-07-23
501	2018-01-01	KEN THOMSON	2019-10-09	KEN THOMSON	2019-10-09
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	TERESA NIEDERT
501	2011-01-01	TERESA NIEDERT
501	2010-01-01	TERESA NIEDERT
501	2009-01-01	TERRI NIEDERT

Plan Statistics for BLACK HORSE CARRIERS, INC. WELFARE PLAN

401k plan membership statisitcs for BLACK HORSE CARRIERS, INC. WELFARE PLAN

Measure Date Value
2022: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,692
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,501
Number of retired or separated participants receiving benefits 2022-01-01 965
Total of all active and inactive participants 2022-01-01 3,466
2021: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,912
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,692
Number of retired or separated participants receiving benefits 2021-01-01 468
Total of all active and inactive participants 2021-01-01 3,160
2020: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,533
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,912
Number of retired or separated participants receiving benefits 2020-01-01 216
Total of all active and inactive participants 2020-01-01 3,128
2019: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,450
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,533
Number of retired or separated participants receiving benefits 2019-01-01 180
Total of all active and inactive participants 2019-01-01 2,713
2018: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,160
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,450
Number of retired or separated participants receiving benefits 2018-01-01 170
Total of all active and inactive participants 2018-01-01 2,620
2017: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,870
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,160
Number of retired or separated participants receiving benefits 2017-01-01 23
Total of all active and inactive participants 2017-01-01 2,183
2016: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,458
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,870
Number of retired or separated participants receiving benefits 2016-01-01 9
Total of all active and inactive participants 2016-01-01 1,879
2015: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,169
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,458
Number of retired or separated participants receiving benefits 2015-01-01 6
Total of all active and inactive participants 2015-01-01 1,464
2014: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 850
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,165
Number of retired or separated participants receiving benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 1,169
2013: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 731
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 850
Total of all active and inactive participants 2013-01-01 850
2012: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 635
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 726
Number of retired or separated participants receiving benefits 2012-01-01 5
Total of all active and inactive participants 2012-01-01 731
2011: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 537
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 630
Number of retired or separated participants receiving benefits 2011-01-01 3
Total of all active and inactive participants 2011-01-01 633
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 2
Total participants 2011-01-01 635
2010: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 691
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 525
Number of retired or separated participants receiving benefits 2010-01-01 12
Total of all active and inactive participants 2010-01-01 537
2009: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 735
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 679
Number of retired or separated participants receiving benefits 2009-01-01 12
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 691

Measure	Date	Value
2022: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,692
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,501
Number of retired or separated participants receiving benefits	2022-01-01	965
Total of all active and inactive participants	2022-01-01	3,466
2021: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,912
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,692
Number of retired or separated participants receiving benefits	2021-01-01	468
Total of all active and inactive participants	2021-01-01	3,160
2020: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,533
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,912
Number of retired or separated participants receiving benefits	2020-01-01	216
Total of all active and inactive participants	2020-01-01	3,128
2019: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,450
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,533
Number of retired or separated participants receiving benefits	2019-01-01	180
Total of all active and inactive participants	2019-01-01	2,713
2018: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,160
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,450
Number of retired or separated participants receiving benefits	2018-01-01	170
Total of all active and inactive participants	2018-01-01	2,620
2017: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,870
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,160
Number of retired or separated participants receiving benefits	2017-01-01	23
Total of all active and inactive participants	2017-01-01	2,183
2016: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,458
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,870
Number of retired or separated participants receiving benefits	2016-01-01	9
Total of all active and inactive participants	2016-01-01	1,879
2015: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,169
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,458
Number of retired or separated participants receiving benefits	2015-01-01	6
Total of all active and inactive participants	2015-01-01	1,464
2014: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	850
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,165
Number of retired or separated participants receiving benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	1,169
2013: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	731
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	850
Total of all active and inactive participants	2013-01-01	850
2012: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	635
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	726
Number of retired or separated participants receiving benefits	2012-01-01	5
Total of all active and inactive participants	2012-01-01	731
2011: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	537
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	630
Number of retired or separated participants receiving benefits	2011-01-01	3
Total of all active and inactive participants	2011-01-01	633
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	2
Total participants	2011-01-01	635
2010: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	691
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	525
Number of retired or separated participants receiving benefits	2010-01-01	12
Total of all active and inactive participants	2010-01-01	537
2009: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	735
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	679
Number of retired or separated participants receiving benefits	2009-01-01	12
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	691

Form 5500 Responses for BLACK HORSE CARRIERS, INC. WELFARE PLAN

2022: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
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: BLACK HORSE CARRIERS, INC. WELFARE PLAN 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: BLACK HORSE CARRIERS, INC. WELFARE PLAN 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: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: BLACK HORSE CARRIERS, INC. WELFARE PLAN 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 benefit arrangement – Insurance	Yes
2010: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: BLACK HORSE CARRIERS, INC. WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

F021902

Policy instance

Insurance contract or identification number	F021902
Number of Individuals Covered	3396
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $290,087
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,466,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $290,087
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

212093

Policy instance

Insurance contract or identification number	212093
Number of Individuals Covered	4445
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $328,464
Total amount of fees paid to insurance company	USD $23,481
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,715,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $328,464
Amount paid for insurance broker fees	23481
Additional information about fees paid to insurance broker	BONUS COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

F021902

Policy instance

Insurance contract or identification number	F021902
Number of Individuals Covered	3431
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $292,256
Total amount of fees paid to insurance company	USD $29,900
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,475,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $292,256
Amount paid for insurance broker fees	29900
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

212093

Policy instance

Insurance contract or identification number	212093
Number of Individuals Covered	4999
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $431,109
Total amount of fees paid to insurance company	USD $26,000
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,956,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $431,109
Amount paid for insurance broker fees	26000
Additional information about fees paid to insurance broker	BONUS COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

212093

Policy instance

Insurance contract or identification number	212093
Number of Individuals Covered	5333
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $389,307
Total amount of fees paid to insurance company	USD $25,620
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,688,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $389,307
Amount paid for insurance broker fees	25620
Additional information about fees paid to insurance broker	BONUS COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

F021902

Policy instance

Insurance contract or identification number	F021902
Number of Individuals Covered	3433
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $275,870
Total amount of fees paid to insurance company	USD $28,715
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,333,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $275,870
Amount paid for insurance broker fees	28715
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

F021902

Policy instance

Insurance contract or identification number	F021902
Number of Individuals Covered	3398
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $261,302
Total amount of fees paid to insurance company	USD $30,000
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,188,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $261,302
Amount paid for insurance broker fees	30000
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

212093

Policy instance

Insurance contract or identification number	212093
Number of Individuals Covered	5303
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $366,070
Total amount of fees paid to insurance company	USD $75,000
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,584,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $366,070
Amount paid for insurance broker fees	75000
Additional information about fees paid to insurance broker	BONUS COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

F021902

Policy instance

Insurance contract or identification number	F021902
Number of Individuals Covered	2804
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $248,461
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,091,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $248,461
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

212093

Policy instance

Insurance contract or identification number	212093
Number of Individuals Covered	4626
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $333,211
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,547,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $333,211
Insurance broker organization code?	3

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

Policy contract number

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	24874
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,306
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	8294
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $157,429
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $173,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $157,429
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

907853

Policy instance

Insurance contract or identification number	907853
Number of Individuals Covered	2139
Insurance policy start date	2017-05-01
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 $197,764
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,886,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	173672
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	7681
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $180,910
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	13128
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,789
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	12557
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $393,826
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	24874
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,147
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	12747
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,730
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

304560

Policy instance

Insurance contract or identification number	304560
Number of Individuals Covered	14671
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,806
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

0907853

Policy instance

Insurance contract or identification number	0907853
Number of Individuals Covered	1833
Insurance policy start date	2017-05-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,654
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,654
Insurance broker organization code?	3
Insurance broker name	ROBERT F BRADLEY

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

Policy contract number

907853

Policy instance

Insurance contract or identification number	907853
Number of Individuals Covered	1999
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $45,496
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,136,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,496
Insurance broker organization code?	3
Insurance broker name	ROBERT F BRADLEY

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	2062
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $935
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $935
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	428
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $17,458
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,458
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	378
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $18,778
Total amount of fees paid to insurance company	USD $17,539
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,778
Amount paid for insurance broker fees	17539
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	2062
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $5,140
Total amount of fees paid to insurance company	USD $1,352
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,140
Amount paid for insurance broker fees	1352
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	913
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $38,560
Total amount of fees paid to insurance company	USD $30,391
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $385,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,560
Amount paid for insurance broker fees	30391
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00613830

Policy instance

Insurance contract or identification number	G00613830
Number of Individuals Covered	654
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $6,263
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,263
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

PB3164

Policy instance

Insurance contract or identification number	PB3164
Number of Individuals Covered	7251
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $347,647
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,720,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $347,647
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-350736

Policy instance

Insurance contract or identification number	010-350736
Number of Individuals Covered	3295
Insurance policy start date	2015-08-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $16,348
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,899
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

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

Policy contract number

902224

Policy instance

Insurance contract or identification number	902224
Number of Individuals Covered	747
Insurance policy start date	2014-05-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $51,253
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,563,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	51253
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	ROBERT F. BRADLEY

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

Policy contract number

VPL 301130

Policy instance

Insurance contract or identification number	VPL 301130
Number of Individuals Covered	266
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $16,073
Total amount of fees paid to insurance company	USD $2,528
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,073
Amount paid for insurance broker fees	2528
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95094 )

Policy contract number

0847989HNO

Policy instance

Insurance contract or identification number	0847989HNO
Number of Individuals Covered	342
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $1,063,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

148620

Policy instance

Insurance contract or identification number	148620
Number of Individuals Covered	165
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $18,631
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $621,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,631
Insurance broker organization code?	3
Insurance broker name	EMPLOYERS BENEFIT GROUP

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

Policy contract number

VPS 326066

Policy instance

Insurance contract or identification number	VPS 326066
Number of Individuals Covered	274
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,870
Total amount of fees paid to insurance company	USD $2,072
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,870
Amount paid for insurance broker fees	2072
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-350736

Policy instance

Insurance contract or identification number	010-350736
Number of Individuals Covered	2899
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $64,053
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $473,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,368
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00112544

Policy instance

Insurance contract or identification number	00112544
Number of Individuals Covered	260
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $72,891
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,891
Insurance broker organization code?	3
Insurance broker name	SUPPORT SERVICTS ALLIANCE INC

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

Policy contract number

GL 150411

Policy instance

Insurance contract or identification number	GL 150411
Number of Individuals Covered	1182
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $46,927
Total amount of fees paid to insurance company	USD $8,024
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $312,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,927
Amount paid for insurance broker fees	8024
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )

Policy contract number

DBL 251774

Policy instance

Insurance contract or identification number	DBL 251774
Number of Individuals Covered	69
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0847989

Policy instance

Insurance contract or identification number	0847989
Number of Individuals Covered	6
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VAI 825084

Policy instance

Insurance contract or identification number	VAI 825084
Number of Individuals Covered	247
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,888
Total amount of fees paid to insurance company	USD $2,209
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,888
Amount paid for insurance broker fees	2209
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SLUTIONS INC

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )

Policy contract number

DBL 251774

Policy instance

Insurance contract or identification number	DBL 251774
Number of Individuals Covered	70
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0847989

Policy instance

Insurance contract or identification number	0847989
Number of Individuals Covered	79
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00112544

Policy instance

Insurance contract or identification number	00112544
Number of Individuals Covered	168
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $70,882
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,882
Insurance broker organization code?	3
Insurance broker name	SUPPORT SERVICTS ALLIANCE INC

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

Policy contract number

VPL 301130

Policy instance

Insurance contract or identification number	VPL 301130
Number of Individuals Covered	274
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,374
Total amount of fees paid to insurance company	USD $1,291
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,374
Amount paid for insurance broker fees	1291
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SOLUTIONS INC

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

Policy contract number

VAI 825084

Policy instance

Insurance contract or identification number	VAI 825084
Number of Individuals Covered	271
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $35,781
Total amount of fees paid to insurance company	USD $1,150
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,781
Amount paid for insurance broker fees	1150
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SOLUTIONS INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-350736

Policy instance

Insurance contract or identification number	010-350736
Number of Individuals Covered	1870
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $79,572
Total amount of fees paid to insurance company	USD $17,019
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $530,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,048
Amount paid for insurance broker fees	11537
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

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

Policy contract number

GL 150411

Policy instance

Insurance contract or identification number	GL 150411
Number of Individuals Covered	1044
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $45,121
Total amount of fees paid to insurance company	USD $3,715
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $298,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,121
Amount paid for insurance broker fees	3715
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SOLUTIONS INC

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

148620

Policy instance

Insurance contract or identification number	148620
Number of Individuals Covered	122
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $12,572
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $419,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,572
Insurance broker organization code?	3
Insurance broker name	EMPLOYERS BENEFIT GROUP

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

Policy contract number

646212

Policy instance

Insurance contract or identification number	646212
Number of Individuals Covered	541
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $91,347
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,347
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

VPS 326066

Policy instance

Insurance contract or identification number	VPS 326066
Number of Individuals Covered	283
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,691
Total amount of fees paid to insurance company	USD $1,083
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,691
Amount paid for insurance broker fees	1083
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SOLUTIONS INC

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

Policy contract number

40000300202202

Policy instance

Insurance contract or identification number	40000300202202
Number of Individuals Covered	250
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $11,644
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,822
Insurance broker organization code?	3
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3335843

Policy instance

Insurance contract or identification number	3335843
Number of Individuals Covered	1383
Insurance policy start date	2012-04-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $16,449
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,449
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

847989

Policy instance

Insurance contract or identification number	847989
Number of Individuals Covered	77
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $8,530
Total amount of fees paid to insurance company	USD $1,855
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,530
Amount paid for insurance broker fees	1855
Additional information about fees paid to insurance broker	2012 MEDICAL NEW SALES SUPPLEMENTAL COMPENSATION
Insurance broker name	KISTLER-TIFFANY BENEFITS

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )

Policy contract number

DBL 251774

Policy instance

Insurance contract or identification number	DBL 251774
Number of Individuals Covered	69
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker name	ASSIGNED AGENT, NO

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

Policy contract number

GL 150411

Policy instance

Insurance contract or identification number	GL 150411
Number of Individuals Covered	1044
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,932
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $93,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,932
Insurance broker organization code?	3
Insurance broker name	ATD EMPLOYER SOLUTIONS INC

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

Policy contract number

10117955

Policy instance

Insurance contract or identification number	10117955
Number of Individuals Covered	898
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $2,724
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $13,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,362
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3335843

Policy instance

Insurance contract or identification number	3335843
Number of Individuals Covered	1370
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $80,670
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $521,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80,670
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

400001000010388

Policy instance

Insurance contract or identification number	400001000010388
Number of Individuals Covered	350
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $19,584
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,792
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-350736

Policy instance

Insurance contract or identification number	010-350736
Number of Individuals Covered	1482
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $20,427
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,618
Insurance broker name	INSENTIAL INC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00112544

Policy instance

Insurance contract or identification number	00112544
Number of Individuals Covered	146
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $54,050
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $960,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,050
Insurance broker organization code?	3
Insurance broker name	SUPPORT SERVICES ALLIANCE INC.

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

Policy contract number

01D022242

Policy instance

Insurance contract or identification number	01D022242
Number of Individuals Covered	221
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $3,727
Total amount of fees paid to insurance company	USD $745
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 $74,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,727
Insurance broker organization code?	3
Amount paid for insurance broker fees	745
Insurance broker name	SOURCE ONE BENEFITS INC

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

Policy contract number

10118629

Policy instance

Insurance contract or identification number	10118629
Number of Individuals Covered	257
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $7,466
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	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $37,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,733
Insurance broker organization code?	3
Insurance broker name	INSENTIAL INC

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

Policy contract number

0711616

Policy instance

Insurance contract or identification number	0711616
Number of Individuals Covered	1308
Insurance policy start date	2012-01-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $21,257
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,037,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,257
Insurance broker organization code?	3
Insurance broker name	ACRISURE LLC

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

Policy contract number

01D022230

Policy instance

Insurance contract or identification number	01D022230
Number of Individuals Covered	338
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $3,630
Total amount of fees paid to insurance company	USD $726
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 $72,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,630
Insurance broker organization code?	3
Amount paid for insurance broker fees	726
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker name	INSENTIAL INC

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

Policy contract number

400001000010388

Policy instance

Insurance contract or identification number	400001000010388
Number of Individuals Covered	371
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $39,126
Total amount of fees paid to insurance company	USD $9,040
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $195,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1807030000

Policy instance

Insurance contract or identification number	1807030000
Number of Individuals Covered	192
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31,354
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $501,664
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

0711616

Policy instance

Insurance contract or identification number	0711616
Number of Individuals Covered	859
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $92,789
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,724,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10117955

Policy instance

Insurance contract or identification number	10117955
Number of Individuals Covered	866
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,204
Total amount of fees paid to insurance company	USD $1,072
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

40000300202202

Policy instance

Insurance contract or identification number	40000300202202
Number of Individuals Covered	242
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $21,444
Total amount of fees paid to insurance company	USD $4,799
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10118629

Policy instance

Insurance contract or identification number	10118629
Number of Individuals Covered	250
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $14,781
Total amount of fees paid to insurance company	USD $3,401
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	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $73,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

01D022230

Policy instance

Insurance contract or identification number	01D022230
Number of Individuals Covered	333
Insurance policy start date	2011-08-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,464
Total amount of fees paid to insurance company	USD $493
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

01D022242

Policy instance

Insurance contract or identification number	01D022242
Number of Individuals Covered	238
Insurance policy start date	2011-08-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,873
Total amount of fees paid to insurance company	USD $575
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 $57,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00112544

Policy instance

Insurance contract or identification number	00112544
Number of Individuals Covered	41
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,398
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $274,316
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

0711616

Policy instance

Insurance contract or identification number	0711616
Number of Individuals Covered	1405
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $97,614
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,629,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $97,614
Insurance broker organization code?	3
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

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

Policy contract number

10117955

Policy instance

Insurance contract or identification number	10117955
Number of Individuals Covered	809
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,286
Total amount of fees paid to insurance company	USD $266
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,637
Insurance broker organization code?	3
Amount paid for insurance broker fees	266
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

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

Policy contract number

400001000010388

Policy instance

Insurance contract or identification number	400001000010388
Number of Individuals Covered	363
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $42,263
Total amount of fees paid to insurance company	USD $2,499
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $180,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,506
Amount paid for insurance broker fees	2499
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

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

Policy contract number

40000300202202

Policy instance

Insurance contract or identification number	40000300202202
Number of Individuals Covered	228
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $19,195
Total amount of fees paid to insurance company	USD $1,293
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,279
Amount paid for insurance broker fees	1293
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

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

Policy contract number

10118629

Policy instance

Insurance contract or identification number	10118629
Number of Individuals Covered	241
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $13,604
Total amount of fees paid to insurance company	USD $914
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	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $68,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,472
Amount paid for insurance broker fees	914
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GLOBAL FINANCIAL SERVICES LLC

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

7499H4

Policy instance

Insurance contract or identification number	7499H4
Number of Individuals Covered	515
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $40,483
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,515
Insurance broker organization code?	3
Insurance broker name	SOURCE ONE BENEFITS

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Company Name:	PENSKE TRUCK LEASING CO., L.P.
Employer identification number (EIN):	364284078
NAIC Classification:	484110
NAIC Description:	General Freight Trucking, Local

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2012-05-14
Company Identification Number:	0801597800
Legal Registered Office Address:	1000 E WARRENVILLE RD STE 200 NAPERVILLE United States of America (USA) 60563