401k Plan data: HAWORTH MEMBER HEALTH AND WELFARE PLAN plan

HAWORTH MEMBER HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	HAWORTH MEMBER HEALTH AND WELFARE PLAN
Plan identification number	501

HAWORTH MEMBER HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

HAWORTH INTERNATIONAL, LTD. has sponsored the creation of one or more 401k plans.

Company Name: HAWORTH INTERNATIONAL, LTD.

Employer identification number (EIN): 382101981

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HAWORTH MEMBER HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 CARL NELSON 2023-10-03
501 2021-01-01 CARL NELSON 2022-10-06
501 2020-01-01 CARL NELSON 2021-09-16
501 2019-01-01 CARL NELSON 2020-10-07
501 2018-01-01 CARL NELSON 2019-10-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 CARL NELSON
501 2011-01-01 CARL NELSON
501 2009-01-01 CARL NELSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	CARL NELSON	2023-10-03
501	2021-01-01	CARL NELSON	2022-10-06
501	2020-01-01	CARL NELSON	2021-09-16
501	2019-01-01	CARL NELSON	2020-10-07
501	2018-01-01	CARL NELSON	2019-10-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	CARL NELSON
501	2011-01-01	CARL NELSON
501	2009-01-01	CARL NELSON

Plan Statistics for HAWORTH MEMBER HEALTH AND WELFARE PLAN

401k plan membership statisitcs for HAWORTH MEMBER HEALTH AND WELFARE PLAN

Measure Date Value
2022: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,244
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,457
Number of retired or separated participants receiving benefits 2022-01-01 18
Total of all active and inactive participants 2022-01-01 2,475
2021: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,587
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,220
Number of retired or separated participants receiving benefits 2021-01-01 24
Total of all active and inactive participants 2021-01-01 2,244
2020: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 3,041
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,538
Number of retired or separated participants receiving benefits 2020-01-01 49
Total of all active and inactive participants 2020-01-01 2,587
2019: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 3,198
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 3,009
Number of retired or separated participants receiving benefits 2019-01-01 32
Total of all active and inactive participants 2019-01-01 3,041
Total participants 2019-01-01 3,041
2018: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 3,126
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 3,168
Number of retired or separated participants receiving benefits 2018-01-01 30
Total of all active and inactive participants 2018-01-01 3,198
2017: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 3,102
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 3,105
Number of retired or separated participants receiving benefits 2017-01-01 21
Total of all active and inactive participants 2017-01-01 3,126
2016: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,813
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 3,052
Number of retired or separated participants receiving benefits 2016-01-01 50
Total of all active and inactive participants 2016-01-01 3,102
2015: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 2,786
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 2,810
Number of retired or separated participants receiving benefits 2015-01-01 3
Total of all active and inactive participants 2015-01-01 2,813
2014: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 2,792
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 2,653
Number of retired or separated participants receiving benefits 2014-01-01 133
Total of all active and inactive participants 2014-01-01 2,786
2013: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 2,771
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 2,782
Number of retired or separated participants receiving benefits 2013-01-01 10
Total of all active and inactive participants 2013-01-01 2,792
2012: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 2,953
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 2,746
Number of retired or separated participants receiving benefits 2012-01-01 25
Total of all active and inactive participants 2012-01-01 2,771
2011: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 2,857
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 2,932
Number of retired or separated participants receiving benefits 2011-01-01 21
Total of all active and inactive participants 2011-01-01 2,953
2009: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 3,521
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 2,413
Number of retired or separated participants receiving benefits 2009-01-01 83
Total of all active and inactive participants 2009-01-01 2,496

Measure	Date	Value
2022: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,244
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,457
Number of retired or separated participants receiving benefits	2022-01-01	18
Total of all active and inactive participants	2022-01-01	2,475
2021: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,587
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,220
Number of retired or separated participants receiving benefits	2021-01-01	24
Total of all active and inactive participants	2021-01-01	2,244
2020: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	3,041
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,538
Number of retired or separated participants receiving benefits	2020-01-01	49
Total of all active and inactive participants	2020-01-01	2,587
2019: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3,198
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	3,009
Number of retired or separated participants receiving benefits	2019-01-01	32
Total of all active and inactive participants	2019-01-01	3,041
Total participants	2019-01-01	3,041
2018: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	3,126
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	3,168
Number of retired or separated participants receiving benefits	2018-01-01	30
Total of all active and inactive participants	2018-01-01	3,198
2017: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	3,102
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	3,105
Number of retired or separated participants receiving benefits	2017-01-01	21
Total of all active and inactive participants	2017-01-01	3,126
2016: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,813
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	3,052
Number of retired or separated participants receiving benefits	2016-01-01	50
Total of all active and inactive participants	2016-01-01	3,102
2015: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,786
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	2,810
Number of retired or separated participants receiving benefits	2015-01-01	3
Total of all active and inactive participants	2015-01-01	2,813
2014: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	2,792
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	2,653
Number of retired or separated participants receiving benefits	2014-01-01	133
Total of all active and inactive participants	2014-01-01	2,786
2013: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,771
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	2,782
Number of retired or separated participants receiving benefits	2013-01-01	10
Total of all active and inactive participants	2013-01-01	2,792
2012: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,953
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,746
Number of retired or separated participants receiving benefits	2012-01-01	25
Total of all active and inactive participants	2012-01-01	2,771
2011: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	2,857
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	2,932
Number of retired or separated participants receiving benefits	2011-01-01	21
Total of all active and inactive participants	2011-01-01	2,953
2009: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	3,521
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	2,413
Number of retired or separated participants receiving benefits	2009-01-01	83
Total of all active and inactive participants	2009-01-01	2,496

Form 5500 Responses for HAWORTH MEMBER HEALTH AND WELFARE PLAN

2022: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: HAWORTH MEMBER HEALTH AND WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HAWORTH MEMBER HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	6120
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $17,623
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,409,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,623
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	421
Insurance policy start date	2022-01-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $40,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	451
Insurance policy start date	2022-08-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $45,197
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

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	2998
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	2457
Insurance policy start date	2021-04-01
Insurance policy end date	2022-04-01
Total amount of commissions paid to insurance broker	USD $6,801
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D, PARALYSIS, EMERGENCY MEDICAL
Welfare Benefit Premiums Paid to Carrier	USD $34,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,801
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682677

Policy instance

Insurance contract or identification number	682677
Number of Individuals Covered	431
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $23,484
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ATTAINED AGE CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $110,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,484
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682678

Policy instance

Insurance contract or identification number	682678
Number of Individuals Covered	521
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $14,313
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $78,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,313

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

LGS02389-22

Policy instance

Insurance contract or identification number	LGS02389-22
Number of Individuals Covered	26257
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $35,906
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,196,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,906

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

Policy contract number

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	5905
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $22,773
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,821,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,773
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	2220
Insurance policy start date	2020-04-01
Insurance policy end date	2021-04-01
Total amount of commissions paid to insurance broker	USD $6,801
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D, PARALYSIS, EMERGENCY MEDICAL
Welfare Benefit Premiums Paid to Carrier	USD $34,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,801
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	380
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $66,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682678

Policy instance

Insurance contract or identification number	682678
Number of Individuals Covered	381
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $11,998
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $78,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,998

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	2795
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682677

Policy instance

Insurance contract or identification number	682677
Number of Individuals Covered	310
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $22,112
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ATTAINED AGE CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $104,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,112
Insurance broker organization code?	3

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

LGS02389-21

Policy instance

Insurance contract or identification number	LGS02389-21
Number of Individuals Covered	26875
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $25,643
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $854,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,643

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	385
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $64,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682677

Policy instance

Insurance contract or identification number	682677
Number of Individuals Covered	253
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $21,359
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ATTAINED AGE CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $95,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,359
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

682678

Policy instance

Insurance contract or identification number	682678
Number of Individuals Covered	299
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $12,318
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $69,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,318

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

Policy contract number

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	6539
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $27,278
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,182,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,278
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	2538
Insurance policy start date	2019-04-01
Insurance policy end date	2020-04-01
Total amount of commissions paid to insurance broker	USD $6,801
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D, PARALYSIS, EMERGENCY MEDICAL
Welfare Benefit Premiums Paid to Carrier	USD $34,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,801
Insurance broker organization code?	3

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	2971
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	3009
Insurance policy start date	2018-04-01
Insurance policy end date	2019-04-01
Total amount of commissions paid to insurance broker	USD $1,568
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D, PARALYSIS, EMERGENCY MEDICAL
Welfare Benefit Premiums Paid to Carrier	USD $7,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,568
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	403
Insurance policy start date	2019-01-01
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 $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $87,918
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

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	7395
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $22,748
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,819,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,748
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	3802
Insurance policy start date	2019-01-01
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 $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	3168
Insurance policy start date	2017-04-01
Insurance policy end date	2018-04-01
Total amount of commissions paid to insurance broker	USD $1,568
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D, PARALYSIS, EMERGENCY MEDICAL
Welfare Benefit Premiums Paid to Carrier	USD $7,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,568
Insurance broker organization code?	3

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	3875
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	330
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $59,118
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

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	3121
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $53,801
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,504,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	35000
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	3552
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
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

413806

Policy instance

Insurance contract or identification number	413806
Number of Individuals Covered	3087
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $39,637
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,585,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	39637
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES - GRAND RAPIDS

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009151086

Policy instance

Insurance contract or identification number	GTP 0009151086
Number of Individuals Covered	3105
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,568
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D AND PARALYSIS
Welfare Benefit Premiums Paid to Carrier	USD $7,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,568
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	411
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $63,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	388
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $60,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2810
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $957
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICK STUIT INS AGENCY

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

Policy contract number

VAR 206032

Policy instance

Insurance contract or identification number	VAR 206032
Number of Individuals Covered	1682
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,786
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $142,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2786
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES CENTRAL INC.

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

Policy contract number

GL 151985

Policy instance

Insurance contract or identification number	GL 151985
Number of Individuals Covered	2770
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $12,500
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $934,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12500
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES CENTRAL INC.

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

Policy contract number

LTD 124844

Policy instance

Insurance contract or identification number	LTD 124844
Number of Individuals Covered	3757
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $5,106
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $277,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5106
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES CENTRAL INC.

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	2002
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VAR 206032

Policy instance

Insurance contract or identification number	VAR 206032
Number of Individuals Covered	1664
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $139,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 151985

Policy instance

Insurance contract or identification number	GL 151985
Number of Individuals Covered	2752
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $896,279
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

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	1893
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	331
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $55,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2653
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $957
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICK STUIT INS AGENCY

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

Policy contract number

LTD 124844

Policy instance

Insurance contract or identification number	LTD 124844
Number of Individuals Covered	3085
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $255,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADDS07395

Policy instance

Insurance contract or identification number	ADDS07395
Number of Individuals Covered	2613
Insurance policy start date	2013-02-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $160,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	330
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $61,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADDS07395

Policy instance

Insurance contract or identification number	ADDS07395
Number of Individuals Covered	2751
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $151,119
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

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	1836
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2782
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $957
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICK STUIT INS AGENCY

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

Policy contract number

674688G

Policy instance

Insurance contract or identification number	674688G
Number of Individuals Covered	2751
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $12,618
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,431,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12618
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING

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

Policy contract number

674688G

Policy instance

Insurance contract or identification number	674688G
Number of Individuals Covered	2723
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $13,629
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,261,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	13629
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $0
Insurance broker name	AON CONSULTING

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

Policy contract number

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	1900
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADDS07395

Policy instance

Insurance contract or identification number	ADDS07395
Number of Individuals Covered	2723
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $144,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	360
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $58,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2746
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $957
Insurance broker organization code?	3
Insurance broker name	BERENDS HENDRICK STUIT INS AGENCY

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

Policy contract number

674688G

Policy instance

Insurance contract or identification number	674688G
Number of Individuals Covered	2913
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $18,417
Total amount of fees paid to insurance company	USD $8,600
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,228,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2932
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $969
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	316
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $58,527
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

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	1957
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADDS07395

Policy instance

Insurance contract or identification number	ADDS07395
Number of Individuals Covered	2913
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $116,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

674688G

Policy instance

Insurance contract or identification number	674688G
Number of Individuals Covered	2794
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $19,444
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $357,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB019789

Policy instance

Insurance contract or identification number	ETB019789
Number of Individuals Covered	2817
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,382
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

0120067

Policy instance

Insurance contract or identification number	0120067
Number of Individuals Covered	2794
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,183,580
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

567100 S001

Policy instance

Insurance contract or identification number	567100 S001
Number of Individuals Covered	1335
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $111,867
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 $10,806,662
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

12011566

Policy instance

Insurance contract or identification number	12011566
Number of Individuals Covered	1865
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

4190010

Policy instance

Insurance contract or identification number	4190010
Number of Individuals Covered	316
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LEGAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $49,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	HAWORTH INTERNATIONAL, LTD.
Employer identification number (EIN):	382101981