401k Plan data: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN plan

IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

IHC, INC. EMPLOYEE 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) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: IHC LLC

Employer identification number (EIN): 381690288

NAIC Classification: 331310

Additional information about IHC LLC

Jurisdiction of Incorporation: Michigan Secretary of State

Incorporation Date: 0000-00-00

Company Identification Number: 143187

Legal Registered Office Address: BURT RD DETROIT 48228

United States of America (USA)
12400

More information about IHC LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 DENICE KAWULA 2023-08-28
501 2021-01-01 JIM HOUCK 2022-10-01
501 2020-01-01 JIM HOUCK 2021-09-07
501 2019-01-01 JIM HOUCK 2020-09-17
501 2018-01-01 JIM HOUCK 2019-10-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	DENICE KAWULA	2023-08-28
501	2021-01-01	JIM HOUCK	2022-10-01
501	2020-01-01	JIM HOUCK	2021-09-07
501	2019-01-01	JIM HOUCK	2020-09-17
501	2018-01-01	JIM HOUCK	2019-10-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01

Plan Statistics for IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 137
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 0
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 0
2021: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 134
Total of all active and inactive participants 2021-01-01 134
2020: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 140
Total of all active and inactive participants 2020-01-01 140
2019: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 164
Total of all active and inactive participants 2019-01-01 164
2018: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 153
Total of all active and inactive participants 2018-01-01 153
2017: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 143
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 144
Total of all active and inactive participants 2017-01-01 144
2016: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 143
Total of all active and inactive participants 2016-01-01 143
2015: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 132
Total of all active and inactive participants 2015-01-01 132
2014: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 120
Total of all active and inactive participants 2014-01-01 120
2013: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 108
Total of all active and inactive participants 2013-01-01 108

Measure	Date	Value
2022: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	137
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	0
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	0
2021: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	134
Total of all active and inactive participants	2021-01-01	134
2020: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	140
Total of all active and inactive participants	2020-01-01	140
2019: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	164
Total of all active and inactive participants	2019-01-01	164
2018: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	153
Total of all active and inactive participants	2018-01-01	153
2017: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	144
Total of all active and inactive participants	2017-01-01	144
2016: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	143
Total of all active and inactive participants	2016-01-01	143
2015: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	132
Total of all active and inactive participants	2015-01-01	132
2014: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	120
Total of all active and inactive participants	2014-01-01	120
2013: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	108
Total of all active and inactive participants	2013-01-01	108

Form 5500 Responses for IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN

2022: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	Yes
2022-01-01	This submission is the final filing	Yes
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan 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: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE 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 benefit arrangement – Insurance	Yes
2017: IHC, INC. EMPLOYEE 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 benefit arrangement – Insurance	Yes
2016: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE 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: IHC, INC. EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	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

GUDE0BJPV

Policy instance

Insurance contract or identification number	GUDE0BJPV
Number of Individuals Covered	58
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,386
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,233
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	133
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,112
Total amount of fees paid to insurance company	USD $67
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,617
Insurance broker organization code?	3
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	FEES

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516-6022

Policy instance

Insurance contract or identification number	1516-6022
Number of Individuals Covered	120
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,085
Total amount of fees paid to insurance company	USD $120
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SAFETY GLASSES
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,085
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICE FEES
Insurance broker organization code?	3

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

Policy contract number

GLUG0BJPV

Policy instance

Insurance contract or identification number	GLUG0BJPV
Number of Individuals Covered	152
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,365
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,243
Insurance broker organization code?	3

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

Policy contract number

GUG 0BJPV

Policy instance

Insurance contract or identification number	GUG 0BJPV
Number of Individuals Covered	152
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,930
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,015
Insurance broker organization code?	3

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

Policy contract number

GUC OBJPV

Policy instance

Insurance contract or identification number	GUC OBJPV
Number of Individuals Covered	44
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $6,975
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,339
Insurance broker organization code?	3

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

Policy contract number

GUDH0BJPV

Policy instance

Insurance contract or identification number	GUDH0BJPV
Number of Individuals Covered	46
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $2,051
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,584
Insurance broker organization code?	3

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

Policy contract number

GVTL0BJPV

Policy instance

Insurance contract or identification number	GVTL0BJPV
Number of Individuals Covered	70
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $4,225
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFE VOLUNTARY, AD&D VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,268
Insurance broker organization code?	3

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

Policy contract number

GUC 0BJPV

Policy instance

Insurance contract or identification number	GUC 0BJPV
Number of Individuals Covered	48
Insurance policy start date	2022-05-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,588
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,460
Insurance broker organization code?	3

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

Policy contract number

GUDH0BJPV

Policy instance

Insurance contract or identification number	GUDH0BJPV
Number of Individuals Covered	60
Insurance policy start date	2022-05-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,404
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,083
Insurance broker organization code?	3

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

Policy contract number

GVTL0BJPV

Policy instance

Insurance contract or identification number	GVTL0BJPV
Number of Individuals Covered	76
Insurance policy start date	2022-05-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,837
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFE VOLUNTARY, AD&D VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,117
Insurance broker organization code?	3

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

Policy contract number

G000BJPV

Policy instance

Insurance contract or identification number	G000BJPV
Number of Individuals Covered	228
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,623
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $112,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,151
Insurance broker organization code?	3

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516-6022/3444

Policy instance

Insurance contract or identification number	1516-6022/3444
Number of Individuals Covered	192
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,085
Total amount of fees paid to insurance company	USD $120
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,085
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

GLUG0BJPV

Policy instance

Insurance contract or identification number	GLUG0BJPV
Number of Individuals Covered	141
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $2,397
Total amount of fees paid to insurance company	USD $550
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,608
Amount paid for insurance broker fees	550
Insurance broker organization code?	4

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	116
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $661
Total amount of fees paid to insurance company	USD $152
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	SAFETY GLASSES
Welfare Benefit Premiums Paid to Carrier	USD $15,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $661
Amount paid for insurance broker fees	152
Insurance broker organization code?	6

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	121
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,559
Total amount of fees paid to insurance company	USD $12,144
Welfare Benefit Premiums Paid to Carrier	USD $355,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,559
Amount paid for insurance broker fees	12144
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	125
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,191
Total amount of fees paid to insurance company	USD $151
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,191
Amount paid for insurance broker fees	151
Insurance broker organization code?	4

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

Policy contract number

GUDE0BJPV

Policy instance

Insurance contract or identification number	GUDE0BJPV
Number of Individuals Covered	57
Insurance policy start date	2021-05-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,575
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $10,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,575
Insurance broker organization code?	4

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

Policy contract number

GUC0BJPV

Policy instance

Insurance contract or identification number	GUC0BJPV
Number of Individuals Covered	49
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $6,684
Total amount of fees paid to insurance company	USD $1,584
Other welfare benefits provided	SHORT TERM DISABILITY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $33,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,442
Amount paid for insurance broker fees	1584
Insurance broker organization code?	4

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

Policy contract number

GUDE0BJPV

Policy instance

Insurance contract or identification number	GUDE0BJPV
Number of Individuals Covered	53
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $2,076
Total amount of fees paid to insurance company	USD $595
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $13,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,390
Amount paid for insurance broker fees	595
Insurance broker organization code?	4

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

Policy contract number

GUDH0BJPV

Policy instance

Insurance contract or identification number	GUDH0BJPV
Number of Individuals Covered	61
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $2,153
Total amount of fees paid to insurance company	USD $635
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $14,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,422
Amount paid for insurance broker fees	635
Insurance broker organization code?	4

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

Policy contract number

GUG0BJPV

Policy instance

Insurance contract or identification number	GUG0BJPV
Number of Individuals Covered	141
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $1,956
Total amount of fees paid to insurance company	USD $463
Other welfare benefits provided	SHORT TERM DISABILITY INSURED
Welfare Benefit Premiums Paid to Carrier	USD $9,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,312
Amount paid for insurance broker fees	463
Insurance broker organization code?	4

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

Policy contract number

GVTL0BJPV

Policy instance

Insurance contract or identification number	GVTL0BJPV
Number of Individuals Covered	85
Insurance policy start date	2020-05-01
Insurance policy end date	2021-05-01
Total amount of commissions paid to insurance broker	USD $4,435
Total amount of fees paid to insurance company	USD $1,367
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $29,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,026
Amount paid for insurance broker fees	1367
Insurance broker organization code?	4

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

Policy contract number

GLUG0BJPV

Policy instance

Insurance contract or identification number	GLUG0BJPV
Number of Individuals Covered	138
Insurance policy start date	2021-05-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,518
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,518
Insurance broker organization code?	4

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

Policy contract number

GUG0BJPV

Policy instance

Insurance contract or identification number	GUG0BJPV
Number of Individuals Covered	138
Insurance policy start date	2021-05-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,239
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SHORT TERM DISABILITY INSURED
Welfare Benefit Premiums Paid to Carrier	USD $6,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,239
Insurance broker organization code?	4

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

Policy contract number

GUDE0BJPV

Policy instance

Insurance contract or identification number	GUDE0BJPV
Number of Individuals Covered	42
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $1,703
Total amount of fees paid to insurance company	USD $139
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $11,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,293
Amount paid for insurance broker fees	139
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

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

Policy contract number

GUDH0BJPV

Policy instance

Insurance contract or identification number	GUDH0BJPV
Number of Individuals Covered	56
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $1,977
Total amount of fees paid to insurance company	USD $174
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $13,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,506
Amount paid for insurance broker fees	174
Insurance broker organization code?	4

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

Policy contract number

GUG0BJPV

Policy instance

Insurance contract or identification number	GUG0BJPV
Number of Individuals Covered	164
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $2,166
Total amount of fees paid to insurance company	USD $142
Other welfare benefits provided	SHORT TERM DISABILITY INSURED
Welfare Benefit Premiums Paid to Carrier	USD $10,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,647
Amount paid for insurance broker fees	142
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

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

Policy contract number

GVTL0BJPV

Policy instance

Insurance contract or identification number	GVTL0BJPV
Number of Individuals Covered	95
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $4,520
Total amount of fees paid to insurance company	USD $407
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $30,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,367
Amount paid for insurance broker fees	407
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

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

Policy contract number

GUC0BJPV

Policy instance

Insurance contract or identification number	GUC0BJPV
Number of Individuals Covered	54
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $7,526
Total amount of fees paid to insurance company	USD $513
Other welfare benefits provided	SHORT TERM DISABILITY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $37,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,693
Amount paid for insurance broker fees	513
Insurance broker organization code?	4

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

Policy contract number

GLUG0BJPV

Policy instance

Insurance contract or identification number	GLUG0BJPV
Number of Individuals Covered	164
Insurance policy start date	2019-05-01
Insurance policy end date	2020-05-01
Total amount of commissions paid to insurance broker	USD $2,424
Total amount of fees paid to insurance company	USD $159
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,843
Amount paid for insurance broker fees	159
Insurance broker organization code?	4

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	129
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,582
Total amount of fees paid to insurance company	USD $15,228
Welfare Benefit Premiums Paid to Carrier	USD $507,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,582
Amount paid for insurance broker fees	13416
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	119
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $604
Total amount of fees paid to insurance company	USD $201
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	SAFETY GLASSES
Welfare Benefit Premiums Paid to Carrier	USD $17,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $604
Amount paid for insurance broker fees	201
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	126
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,542
Total amount of fees paid to insurance company	USD $695
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,542
Amount paid for insurance broker fees	695
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	148
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,112
Total amount of fees paid to insurance company	USD $634
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,112
Amount paid for insurance broker fees	634
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	137
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $240
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	SAFETY GLASSES
Welfare Benefit Premiums Paid to Carrier	USD $18,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	240
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	150
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $15,665
Total amount of fees paid to insurance company	USD $14,721
Welfare Benefit Premiums Paid to Carrier	USD $440,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,665
Amount paid for insurance broker fees	13065
Insurance broker organization code?	3

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

Policy contract number

907479

Policy instance

Insurance contract or identification number	907479
Number of Individuals Covered	151
Insurance policy start date	2018-05-01
Insurance policy end date	2019-04-30
Total amount of commissions paid to insurance broker	USD $13,508
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $76,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,508
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	137
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,835
Total amount of fees paid to insurance company	USD $738
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,835
Amount paid for insurance broker fees	738
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	136
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,940
Total amount of fees paid to insurance company	USD $12,696
Welfare Benefit Premiums Paid to Carrier	USD $422,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,499
Amount paid for insurance broker fees	12696
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	124
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $584
Total amount of fees paid to insurance company	USD $162
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	SAFETY GLASSES
Welfare Benefit Premiums Paid to Carrier	USD $17,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $584
Amount paid for insurance broker fees	162
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5475881

Policy instance

Insurance contract or identification number	5475881
Number of Individuals Covered	146
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $2,364
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,364
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

4054946

Policy instance

Insurance contract or identification number	4054946
Number of Individuals Covered	58
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $3,515
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $49,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,515
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	127
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,528
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,528
Insurance broker name	AFFILIATED AGENCIES LLC

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	117
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $972
Total amount of fees paid to insurance company	USD $120
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	SAFETY GLASSES
Welfare Benefit Premiums Paid to Carrier	USD $16,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $972
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	128
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,542
Total amount of fees paid to insurance company	USD $12,048
Welfare Benefit Premiums Paid to Carrier	USD $347,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,066
Amount paid for insurance broker fees	12048
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5475881

Policy instance

Insurance contract or identification number	5475881
Number of Individuals Covered	139
Insurance policy start date	2016-05-01
Insurance policy end date	2017-04-30
Total amount of commissions paid to insurance broker	USD $1,799
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,799
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

4054946

Policy instance

Insurance contract or identification number	4054946
Number of Individuals Covered	57
Insurance policy start date	2016-05-01
Insurance policy end date	2017-04-30
Total amount of commissions paid to insurance broker	USD $9,656
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $45,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,656
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	123
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,474
Total amount of fees paid to insurance company	USD $10,872
Welfare Benefit Premiums Paid to Carrier	USD $318,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,994
Amount paid for insurance broker fees	10872
Additional information about fees paid to insurance broker	AGENT FEE
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	108
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,023
Total amount of fees paid to insurance company	USD $120
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,023
Amount paid for insurance broker fees	120
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	119
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,495
Total amount of fees paid to insurance company	USD $717
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,495
Amount paid for insurance broker fees	717
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

SECURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68721 )

Policy contract number

35617

Policy instance

Insurance contract or identification number	35617
Number of Individuals Covered	120
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $1,741
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,741
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	109
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,614
Total amount of fees paid to insurance company	USD $686
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 $11,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,531
Amount paid for insurance broker fees	686
Insurance broker organization code?	3
Insurance broker name	LUCIDO MORRIS ASSOCIATES, LLC

SECURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68721 )

Policy contract number

35617

Policy instance

Insurance contract or identification number	35617
Number of Individuals Covered	115
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,689
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,689
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

ADMIN RESOURCES INTERACTIVE (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	100
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,001
Total amount of fees paid to insurance company	USD $120
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 $14,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,001
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	BILLING FEES.
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	113
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,655
Total amount of fees paid to insurance company	USD $10,236
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 $307,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,548
Amount paid for insurance broker fees	10236
Additional information about fees paid to insurance broker	AGENT FEE
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

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

Policy contract number

142556

Policy instance

Insurance contract or identification number	142556
Number of Individuals Covered	104
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,428
Total amount of fees paid to insurance company	USD $11,990
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 $283,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,707
Amount paid for insurance broker fees	11990
Additional information about fees paid to insurance broker	AGENT FEE
Insurance broker organization code?	3
Insurance broker name	AFFILIATED AGENCIES LLC

ADMIN RESOURCES INTERACTIVE (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

1516

Policy instance

Insurance contract or identification number	1516
Number of Individuals Covered	96
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $999
Total amount of fees paid to insurance company	USD $120
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 $14,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $999
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	BILLING FEES
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00455114

Policy instance

Insurance contract or identification number	00455114
Number of Individuals Covered	103
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,692
Total amount of fees paid to insurance company	USD $606
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 $9,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,725
Amount paid for insurance broker fees	606
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	LUCIDO MORRIS ASSOCIATES, LLC

SECURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68721 )

Policy contract number

35617

Policy instance

Insurance contract or identification number	35617
Number of Individuals Covered	109
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $1,526
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,526
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL BENEFIT PLANNERS

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Company Name:	IHC LLC
Employer identification number (EIN):	381690288
NAIC Classification:	331310

Jurisdiction of Incorporation:	Michigan Secretary of State
Incorporation Date:	0000-00-00
Company Identification Number:	143187
Legal Registered Office Address:	BURT RD DETROIT 48228 United States of America (USA) 12400