401k Plan data: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN plan

LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN
Plan identification number	501

LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN, INC. has sponsored the creation of one or more 401k plans.

Company Name: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN, INC.

Employer identification number (EIN): 381359524

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01 AMY STORMS AMY STORMS 2015-08-04
501 2013-01-01 AMY STORMS AMY STORMS 2014-10-13
501 2012-01-01 AMY STORMS AMY STORMS 2013-10-14
501 2011-01-01 AMY STORMS AMY STORMS 2012-10-12
501 2010-01-01 RONALD SALVNER RONALD SALVNER 2011-08-22
501 2009-01-01 MICHEL BARTH MICHEL BARTH 2010-10-13

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01	AMY STORMS	AMY STORMS	2015-08-04
501	2013-01-01	AMY STORMS	AMY STORMS	2014-10-13
501	2012-01-01	AMY STORMS	AMY STORMS	2013-10-14
501	2011-01-01	AMY STORMS	AMY STORMS	2012-10-12
501	2010-01-01	RONALD SALVNER	RONALD SALVNER	2011-08-22
501	2009-01-01	MICHEL BARTH	MICHEL BARTH	2010-10-13

Plan Statistics for LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN

401k plan membership statisitcs for LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN

Measure Date Value
2021: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 276
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 321
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 2021-01-01 321
2020: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 276
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 276
2019: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 287
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 287
2018: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 269
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 269
Number of employers contributing to the scheme 2018-01-01 0
2017: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 254
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 257
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 257
2016: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 345
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 254
Number of retired or separated participants receiving benefits 2016-01-01 48
Total of all active and inactive participants 2016-01-01 302
2015: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 262
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 304
Number of retired or separated participants receiving benefits 2015-01-01 41
Total of all active and inactive participants 2015-01-01 345
2014: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 262
Total of all active and inactive participants 2014-01-01 262
2013: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 285
Total of all active and inactive participants 2013-01-01 285
2012: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 285
Total of all active and inactive participants 2012-01-01 285
2011: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 307
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 287
Total of all active and inactive participants 2011-01-01 287
2010: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 343
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 307
Total of all active and inactive participants 2010-01-01 307
2009: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 340
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 343
Total of all active and inactive participants 2009-01-01 343

Measure	Date	Value
2021: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	276
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	321
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	321
2020: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	276
Number of retired or separated participants receiving benefits	2020-01-01	0
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	276
2019: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	287
Number of retired or separated participants receiving benefits	2019-01-01	0
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	287
2018: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	269
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	269
Number of employers contributing to the scheme	2018-01-01	0
2017: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	254
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	257
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	257
2016: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	345
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	254
Number of retired or separated participants receiving benefits	2016-01-01	48
Total of all active and inactive participants	2016-01-01	302
2015: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	262
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	304
Number of retired or separated participants receiving benefits	2015-01-01	41
Total of all active and inactive participants	2015-01-01	345
2014: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	262
Total of all active and inactive participants	2014-01-01	262
2013: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	285
Total of all active and inactive participants	2013-01-01	285
2012: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	285
Total of all active and inactive participants	2012-01-01	285
2011: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	307
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	287
Total of all active and inactive participants	2011-01-01	287
2010: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	343
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	307
Total of all active and inactive participants	2010-01-01	307
2009: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	343
Total of all active and inactive participants	2009-01-01	343

Form 5500 Responses for LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN

2021: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2015: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2014: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2013: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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 benefit arrangement – Insurance	Yes
2012: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 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 benefit arrangement – Insurance	Yes
2011: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT 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: LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN DBA WELLSPRING LUTHERAN SERVICES WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GVTL0BSZW

Policy instance

Insurance contract or identification number	GVTL0BSZW
Number of Individuals Covered	83
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,287
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,287
Insurance broker organization code?	3

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

T60104

Policy instance

Insurance contract or identification number	T60104
Number of Individuals Covered	31
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,457
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,457
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

100523

Policy instance

Insurance contract or identification number	100523
Number of Individuals Covered	158
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $30,316
Total amount of fees paid to insurance company	USD $1,836
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 $30,316
Amount paid for insurance broker fees	1836
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	182
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

2813

Policy instance

Insurance contract or identification number	2813
Number of Individuals Covered	299
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,036
Total amount of fees paid to insurance company	USD $256
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,036
Amount paid for insurance broker fees	256
Additional information about fees paid to insurance broker	RETENTION BONUS
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

71105-5

Policy instance

Insurance contract or identification number	71105-5
Number of Individuals Covered	136
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $6,986
Total amount of fees paid to insurance company	USD $545
Other welfare benefits provided	VOLUNTARY: ACCIDENT AND CRITICAL IL
Welfare Benefit Premiums Paid to Carrier	USD $27,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,986
Amount paid for insurance broker fees	545
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3

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

Policy contract number

GLTD0BSZW

Policy instance

Insurance contract or identification number	GLTD0BSZW
Number of Individuals Covered	28
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,463
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,463
Insurance broker organization code?	3

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

Policy contract number

GLUG0BSZW

Policy instance

Insurance contract or identification number	GLUG0BSZW
Number of Individuals Covered	321
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,050
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $51,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,050
Insurance broker organization code?	3

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

Policy contract number

GUPR0BSZW

Policy instance

Insurance contract or identification number	GUPR0BSZW
Number of Individuals Covered	34
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

T60104

Policy instance

Insurance contract or identification number	T60104
Number of Individuals Covered	29
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $8,219
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $164,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,219
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

100523

Policy instance

Insurance contract or identification number	100523
Number of Individuals Covered	156
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $30,954
Total amount of fees paid to insurance company	USD $1,776
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 $30,954
Amount paid for insurance broker fees	1776
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	169
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0002813

Policy instance

Insurance contract or identification number	0002813
Number of Individuals Covered	320
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $2,170
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,170
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

837034

Policy instance

Insurance contract or identification number	837034
Number of Individuals Covered	276
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,439
Total amount of fees paid to insurance company	USD $1,747
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $61,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,439
Amount paid for insurance broker fees	1747
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

837035

Policy instance

Insurance contract or identification number	837035
Number of Individuals Covered	71
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,857
Total amount of fees paid to insurance company	USD $542
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,857
Amount paid for insurance broker fees	542
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0002813

Policy instance

Insurance contract or identification number	0002813
Number of Individuals Covered	323
Insurance policy start date	2020-12-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $154
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

71105-5

Policy instance

Insurance contract or identification number	71105-5
Number of Individuals Covered	104
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $5,602
Other welfare benefits provided	VOLUNTARY: ACCIDENT AND CRITICAL IL
Welfare Benefit Premiums Paid to Carrier	USD $21,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,602
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	177
Insurance policy start date	2020-12-01
Insurance policy end date	2020-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

T60104

Policy instance

Insurance contract or identification number	T60104
Number of Individuals Covered	29
Insurance policy start date	2020-12-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,302
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,302
Insurance broker organization code?	3

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	38
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $11,509
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $233,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,509
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

100523

Policy instance

Insurance contract or identification number	100523
Number of Individuals Covered	150
Insurance policy start date	2018-12-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $30,442
Total amount of fees paid to insurance company	USD $870
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 $30,442
Amount paid for insurance broker fees	870
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	174
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

2813

Policy instance

Insurance contract or identification number	2813
Number of Individuals Covered	322
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $2,035
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,035
Insurance broker organization code?	3

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

Policy contract number

EAB1000111

Policy instance

Insurance contract or identification number	EAB1000111
Number of Individuals Covered	266
Insurance policy start date	2018-12-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $3,972
Total amount of fees paid to insurance company	USD $7,047
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $36,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,972
Amount paid for insurance broker fees	7047
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

837034

Policy instance

Insurance contract or identification number	837034
Number of Individuals Covered	287
Insurance policy start date	2019-04-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,408
Total amount of fees paid to insurance company	USD $4,058
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $81,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,408
Amount paid for insurance broker fees	4058
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

837035

Policy instance

Insurance contract or identification number	837035
Number of Individuals Covered	79
Insurance policy start date	2019-04-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,503
Total amount of fees paid to insurance company	USD $768
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,503
Amount paid for insurance broker fees	768
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	42
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $9,874
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $197,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,874
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

100523

Policy instance

Insurance contract or identification number	100523
Number of Individuals Covered	160
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $28,006
Total amount of fees paid to insurance company	USD $1,639
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 $28,006
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	173
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

2813

Policy instance

Insurance contract or identification number	2813
Number of Individuals Covered	338
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $2,318
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,318
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

468072

Policy instance

Insurance contract or identification number	468072
Number of Individuals Covered	269
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $7,321
Total amount of fees paid to insurance company	USD $1,748
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $80,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,321
Amount paid for insurance broker fees	1748
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

468073

Policy instance

Insurance contract or identification number	468073
Number of Individuals Covered	95
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $2,917
Total amount of fees paid to insurance company	USD $389
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,917
Amount paid for insurance broker fees	389
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104COBR

Policy instance

Insurance contract or identification number	M60104COBR
Number of Individuals Covered	0
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

468072

Policy instance

Insurance contract or identification number	468072
Number of Individuals Covered	263
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $9,428
Total amount of fees paid to insurance company	USD $1,697
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $98,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,463
Amount paid for insurance broker fees	939
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

2813

Policy instance

Insurance contract or identification number	2813
Number of Individuals Covered	350
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $1,356
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $794
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	154
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $660
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $660
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

100523

Policy instance

Insurance contract or identification number	100523
Number of Individuals Covered	148
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $32,500
Total amount of fees paid to insurance company	USD $2,222
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 $22,925
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS
Insurance broker name	BERENDS HENDRICKS STUIT INS AGENCY

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	50
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $7,776
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $157,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,743
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	77
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $13,163
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $295,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,163
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	144
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $1,359
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,359
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

100523/001,002

Policy instance

Insurance contract or identification number	100523/001,002
Number of Individuals Covered	12
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $2,295
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,295
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0002813

Policy instance

Insurance contract or identification number	0002813
Number of Individuals Covered	401
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $4,091
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,091
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

468072, 468073

Policy instance

Insurance contract or identification number	468072, 468073
Number of Individuals Covered	304
Insurance policy start date	2015-01-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $11,236
Total amount of fees paid to insurance company	USD $4,057
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,236
Amount paid for insurance broker fees	4057
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

CID 100523

Policy instance

Insurance contract or identification number	CID 100523
Number of Individuals Covered	133
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $39,135
Total amount of fees paid to insurance company	USD $2,080
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 $30,521
Insurance broker organization code?	3
Amount paid for insurance broker fees	2080
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	50
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $5,984
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 $132,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,984
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

CID 100523

Policy instance

Insurance contract or identification number	CID 100523
Number of Individuals Covered	159
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $33,490
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 $23,590
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	162
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $1,278
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,278
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

100523/001,002

Policy instance

Insurance contract or identification number	100523/001,002
Number of Individuals Covered	52
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $9,558
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $203,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,558
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

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

Policy contract number

KM05980793

Policy instance

Insurance contract or identification number	KM05980793
Number of Individuals Covered	582
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $4,485
Total amount of fees paid to insurance company	USD $1,202
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 $159,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,485
Amount paid for insurance broker fees	1202
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

07378

Policy instance

Insurance contract or identification number	07378
Number of Individuals Covered	305
Insurance policy start date	2014-01-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $7,708
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,708
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

07378

Policy instance

Insurance contract or identification number	07378
Number of Individuals Covered	285
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,018
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,018
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

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

Policy contract number

KM05980793

Policy instance

Insurance contract or identification number	KM05980793
Number of Individuals Covered	614
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $4,194
Total amount of fees paid to insurance company	USD $679
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 $157,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,194
Amount paid for insurance broker fees	679
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

100523/001,002

Policy instance

Insurance contract or identification number	100523/001,002
Number of Individuals Covered	96
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $14,717
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 $351,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,717
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	162
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $1,256
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,256
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	68
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $9,467
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 $210,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,467
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

07378

Policy instance

Insurance contract or identification number	07378
Number of Individuals Covered	329
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,115
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,115
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )

Policy contract number

780267 S001

Policy instance

Insurance contract or identification number	780267 S001
Number of Individuals Covered	10
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $1,235
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 $30,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,235
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	53
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $6,335
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 $169,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,335
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

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

Policy contract number

KM05980793

Policy instance

Insurance contract or identification number	KM05980793
Number of Individuals Covered	639
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $4,767
Total amount of fees paid to insurance company	USD $564
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 $162,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,767
Amount paid for insurance broker fees	564
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00100523/0001

Policy instance

Insurance contract or identification number	00100523/0001
Number of Individuals Covered	205
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $16,140
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 $741,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,140
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	160
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,257
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,257
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICKS STUIT INS. AGENCY

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	162
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,300
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	48
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $5,645
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 $104,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

100523/001,002

Policy instance

Insurance contract or identification number	100523/001,002
Number of Individuals Covered	248
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $22,776
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 $876,396
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

KM05980793

Policy instance

Insurance contract or identification number	KM05980793
Number of Individuals Covered	660
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $4,358
Total amount of fees paid to insurance company	USD $3,077
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 $167,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )

Policy contract number

780267 S001

Policy instance

Insurance contract or identification number	780267 S001
Number of Individuals Covered	88
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $15,179
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 $379,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

07378

Policy instance

Insurance contract or identification number	07378
Number of Individuals Covered	287
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,448
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60104

Policy instance

Insurance contract or identification number	M60104
Number of Individuals Covered	34
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $9,364
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 $156,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30011285

Policy instance

Insurance contract or identification number	30011285
Number of Individuals Covered	167
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $1,457
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

100523/001,002

Policy instance

Insurance contract or identification number	100523/001,002
Number of Individuals Covered	188
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $34,715
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 $796,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0001856

Policy instance

Insurance contract or identification number	0001856
Number of Individuals Covered	537
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $5,428
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )

Policy contract number

780267 S001

Policy instance

Insurance contract or identification number	780267 S001
Number of Individuals Covered	46
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $15,044
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 $376,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

07378

Policy instance

Insurance contract or identification number	07378
Number of Individuals Covered	307
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,376
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $179,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	LUTHERAN CHILD & FAMILY SERVICE OF MICHIGAN, INC.
Employer identification number (EIN):	381359524
NAIC Classification:	624100
NAIC Description:	Individual and Family Services