401k Plan data: LAFONTAINE AUTO GROUP HEALTH PLAN plan

LAFONTAINE AUTO GROUP HEALTH PLAN 401k Plan overview

Plan Name	LAFONTAINE AUTO GROUP HEALTH PLAN
Plan identification number	501

LAFONTAINE AUTO GROUP HEALTH PLAN Benefits

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

401k Sponsoring company profile

LAFONTAINE MOTORS, INC. has sponsored the creation of one or more 401k plans.

Company Name: LAFONTAINE MOTORS, INC.

Employer identification number (EIN): 382307028

NAIC Classification: 444110
NAIC Description: Home Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LAFONTAINE AUTO GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 MARISSA HUNT 2023-05-20
501 2021-01-01 MARISSA HUNT 2022-05-20
501 2020-01-01 MARISSA HUNT 2021-06-29
501 2019-01-01 MARISSA HUNT 2020-06-22
501 2018-01-01 MARISSA HUNT 2020-05-13
501 2017-01-01 MARISSA HUNT 2020-05-13
501 2016-01-01 MARISSA HUNT 2020-05-13
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 CHRISTINE RUSSELL
501 2011-01-01 CHRISTINE RUSSELL
501 2009-01-01 CHRISTINE RUSSELL
501 2008-01-01 CHRISTINE RUSSELL

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	MARISSA HUNT	2023-05-20
501	2021-01-01	MARISSA HUNT	2022-05-20
501	2020-01-01	MARISSA HUNT	2021-06-29
501	2019-01-01	MARISSA HUNT	2020-06-22
501	2018-01-01	MARISSA HUNT	2020-05-13
501	2017-01-01	MARISSA HUNT	2020-05-13
501	2016-01-01	MARISSA HUNT	2020-05-13
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	CHRISTINE RUSSELL
501	2011-01-01	CHRISTINE RUSSELL
501	2009-01-01	CHRISTINE RUSSELL
501	2008-01-01	CHRISTINE RUSSELL

Plan Statistics for LAFONTAINE AUTO GROUP HEALTH PLAN

401k plan membership statisitcs for LAFONTAINE AUTO GROUP HEALTH PLAN

Measure Date Value
2022: LAFONTAINE AUTO GROUP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 382
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 517
Total of all active and inactive participants 2022-01-01 517
2021: LAFONTAINE AUTO GROUP HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 442
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 382
Total of all active and inactive participants 2021-01-01 382
2020: LAFONTAINE AUTO GROUP HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 408
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 442
Total of all active and inactive participants 2020-01-01 442
2019: LAFONTAINE AUTO GROUP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 428
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 408
Total of all active and inactive participants 2019-01-01 408
2018: LAFONTAINE AUTO GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 518
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 428
Total of all active and inactive participants 2018-01-01 428
2017: LAFONTAINE AUTO GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 717
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 518
Total of all active and inactive participants 2017-01-01 518
2016: LAFONTAINE AUTO GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 799
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 717
Total of all active and inactive participants 2016-01-01 717
2015: LAFONTAINE AUTO GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 690
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 799
Total of all active and inactive participants 2015-01-01 799
2014: LAFONTAINE AUTO GROUP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 716
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 690
Total of all active and inactive participants 2014-01-01 690
2013: LAFONTAINE AUTO GROUP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 709
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 716
Total of all active and inactive participants 2013-01-01 716
2012: LAFONTAINE AUTO GROUP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 641
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 709
Total of all active and inactive participants 2012-01-01 709
2011: LAFONTAINE AUTO GROUP HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 228
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 641
Total of all active and inactive participants 2011-01-01 641
2009: LAFONTAINE AUTO GROUP HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 218
Total of all active and inactive participants 2009-01-01 218
2008: LAFONTAINE AUTO GROUP HEALTH PLAN 2008 401k membership
Total participants, beginning-of-year 2008-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2008-01-01 188
Total of all active and inactive participants 2008-01-01 188

Measure	Date	Value
2022: LAFONTAINE AUTO GROUP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	382
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	517
Total of all active and inactive participants	2022-01-01	517
2021: LAFONTAINE AUTO GROUP HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	442
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	382
Total of all active and inactive participants	2021-01-01	382
2020: LAFONTAINE AUTO GROUP HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	408
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	442
Total of all active and inactive participants	2020-01-01	442
2019: LAFONTAINE AUTO GROUP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	408
Total of all active and inactive participants	2019-01-01	408
2018: LAFONTAINE AUTO GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	518
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	428
Total of all active and inactive participants	2018-01-01	428
2017: LAFONTAINE AUTO GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	717
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	518
Total of all active and inactive participants	2017-01-01	518
2016: LAFONTAINE AUTO GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	799
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	717
Total of all active and inactive participants	2016-01-01	717
2015: LAFONTAINE AUTO GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	690
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	799
Total of all active and inactive participants	2015-01-01	799
2014: LAFONTAINE AUTO GROUP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	716
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	690
Total of all active and inactive participants	2014-01-01	690
2013: LAFONTAINE AUTO GROUP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	709
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	716
Total of all active and inactive participants	2013-01-01	716
2012: LAFONTAINE AUTO GROUP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	641
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	709
Total of all active and inactive participants	2012-01-01	709
2011: LAFONTAINE AUTO GROUP HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	228
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	641
Total of all active and inactive participants	2011-01-01	641
2009: LAFONTAINE AUTO GROUP HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	218
Total of all active and inactive participants	2009-01-01	218
2008: LAFONTAINE AUTO GROUP HEALTH PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	188
Total of all active and inactive participants	2008-01-01	188

Form 5500 Responses for LAFONTAINE AUTO GROUP HEALTH PLAN

2022: LAFONTAINE AUTO GROUP HEALTH 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 benefit arrangement – Insurance	Yes
2021: LAFONTAINE AUTO GROUP HEALTH 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 benefit arrangement – Insurance	Yes
2020: LAFONTAINE AUTO GROUP HEALTH 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 benefit arrangement – Insurance	Yes
2019: LAFONTAINE AUTO GROUP HEALTH 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 benefit arrangement – Insurance	Yes
2018: LAFONTAINE AUTO GROUP HEALTH 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: LAFONTAINE AUTO GROUP HEALTH 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: LAFONTAINE AUTO GROUP HEALTH PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: LAFONTAINE AUTO GROUP HEALTH 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: LAFONTAINE AUTO GROUP HEALTH 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: LAFONTAINE AUTO GROUP HEALTH PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: LAFONTAINE AUTO GROUP HEALTH PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: LAFONTAINE AUTO GROUP HEALTH PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: LAFONTAINE AUTO GROUP HEALTH 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 benefit arrangement – Insurance	Yes
2008: LAFONTAINE AUTO GROUP HEALTH PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	First time form 5500 has been submitted	Yes
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	347
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $16,030
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $80,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,416
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	517
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $40,010
Total amount of fees paid to insurance company	USD $2,486
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,010
Insurance broker organization code?	3
Amount paid for insurance broker fees	2486

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	871
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $60,342
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $603,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60,342
Insurance broker organization code?	3

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	368
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $21,979
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $146,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,979
Insurance broker organization code?	3

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	325
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $23,212
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,212
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	1024
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $59,168
Total amount of fees paid to insurance company	USD $6,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,168
Insurance broker organization code?	3
Amount paid for insurance broker fees	6617

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	640
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,864
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,864
Insurance broker organization code?	3

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	1524
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $44,997
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $224,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,748
Insurance broker organization code?	3

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	400
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,541
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,209
Insurance broker organization code?	0

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

Policy contract number

LTD 125487

Policy instance

Insurance contract or identification number	LTD 125487
Number of Individuals Covered	8
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $537
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $537
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	382
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $32,943
Total amount of fees paid to insurance company	USD $2,397
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,943
Insurance broker organization code?	3
Amount paid for insurance broker fees	2397

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	1608
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $47,082
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $470,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,082
Insurance broker organization code?	3

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	336
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $18,595
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $123,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,595
Insurance broker organization code?	3

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	271
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $20,205
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $134,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,205
Insurance broker organization code?	3

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	283
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,112
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $70,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,409
Insurance broker organization code?	3

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	577
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,710
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,710
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	950
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $61,816
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,053
Insurance broker organization code?	3

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

Policy contract number

LTD 125487

Policy instance

Insurance contract or identification number	LTD 125487
Number of Individuals Covered	8
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $570
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $570
Insurance broker organization code?	3

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	354
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $16,225
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,518
Insurance broker organization code?	0

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	1166
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $38,349
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,762
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	442
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $23,898
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,240
Insurance broker organization code?	3

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	1357
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $47,030
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $470,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,030
Insurance broker organization code?	3

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	283
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $18,400
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $122,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,400
Insurance broker organization code?	3

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	207
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $19,840
Total amount of fees paid to insurance company	USD $1,353
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,840
Amount paid for insurance broker fees	1353
Insurance broker organization code?	3

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	261
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $17,456
Total amount of fees paid to insurance company	USD $256
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $73,242
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
Amount paid for insurance broker fees	256

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	519
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,694
Total amount of fees paid to insurance company	USD $134
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,694
Amount paid for insurance broker fees	134
Insurance broker organization code?	3

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	686
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $36,116
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,891
Insurance broker organization code?	3

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

Policy contract number

LTD 125487

Policy instance

Insurance contract or identification number	LTD 125487
Number of Individuals Covered	9
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $679
Total amount of fees paid to insurance company	USD $62
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $679
Amount paid for insurance broker fees	62
Insurance broker organization code?	3

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	324
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $20,137
Total amount of fees paid to insurance company	USD $294
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,132
Insurance broker organization code?	0
Amount paid for insurance broker fees	294

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	982
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $31,329
Total amount of fees paid to insurance company	USD $1,718
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,497
Amount paid for insurance broker fees	1718
Insurance broker organization code?	3

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	42
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $49,315
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,998
Insurance broker organization code?	4

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	570
Insurance policy start date	2019-11-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,976
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,976

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	393
Insurance policy start date	2019-11-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $15,586
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,586

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	549
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $29,365
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,703

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

Policy contract number

LTD 125487

Policy instance

Insurance contract or identification number	LTD 125487
Number of Individuals Covered	6
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $870
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $618
Insurance broker organization code?	7

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	355
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $25,502
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,274
Insurance broker organization code?	3

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	121
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $1,471
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,340
Insurance broker organization code?	3

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	34
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $42,884
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $59,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,836
Insurance broker organization code?	3

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	55
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $14,649
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,533
Insurance broker organization code?	3

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	63
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $14,624
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $97,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,643
Insurance broker organization code?	3

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	1157
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $35,084
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $373,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,084

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	408
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $26,757
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,239
Insurance broker organization code?	3

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	128
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $2,867
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,867
Insurance broker organization code?	4

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

13866

Policy instance

Insurance contract or identification number	13866
Number of Individuals Covered	119
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $16,049
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,029
Insurance broker organization code?	3

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	838
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $19,144
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,358
Insurance broker organization code?	3

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	386
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $1,113
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,113
Insurance broker organization code?	3

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	970
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $24,593
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $364,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,593

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	428
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $30,772
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,765
Insurance broker organization code?	3

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	201
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $8,063
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $53,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,063

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	175
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $11,377
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,377
Insurance broker organization code?	3

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	121
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $3,290
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $32,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,290
Insurance broker organization code?	3

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	175
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $10,738
Total amount of fees paid to insurance company	USD $1,979
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,589
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

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	840
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $19,869
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $294,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

267881

Policy instance

Insurance contract or identification number	267881
Number of Individuals Covered	518
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $39,112
Total amount of fees paid to insurance company	USD $0
Health 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

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	191
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $8,052
Total amount of fees paid to insurance company	USD $1,469
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $53,679
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

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	104
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $3,487
Total amount of fees paid to insurance company	USD $1,098
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

13866

Policy instance

Insurance contract or identification number	13866
Number of Individuals Covered	141
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $33,954
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $212,110
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 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	809
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $20,163
Total amount of fees paid to insurance company	USD $2,796
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,808
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 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	400
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $1,144
Total amount of fees paid to insurance company	USD $249
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VAI 825330

Policy instance

Insurance contract or identification number	VAI 825330
Number of Individuals Covered	116
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $2,873
Total amount of fees paid to insurance company	USD $830
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $28,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

52389

Policy instance

Insurance contract or identification number	52389
Number of Individuals Covered	799
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $47,255
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,255
Insurance broker organization code?	3
Insurance broker name	INSURANCE CONSULTING ASSOC

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

Policy contract number

VPL 301611

Policy instance

Insurance contract or identification number	VPL 301611
Number of Individuals Covered	164
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $9,172
Total amount of fees paid to insurance company	USD $168
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,172
Amount paid for insurance broker fees	168
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

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

Policy contract number

VCI 800326

Policy instance

Insurance contract or identification number	VCI 800326
Number of Individuals Covered	101
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $18,689
Total amount of fees paid to insurance company	USD $82
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $28,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,689
Amount paid for insurance broker fees	82
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

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

Policy contract number

VAR 206320

Policy instance

Insurance contract or identification number	VAR 206320
Number of Individuals Covered	411
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,150
Total amount of fees paid to insurance company	USD $20
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,150
Amount paid for insurance broker fees	20
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

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

Policy contract number

GL 153061

Policy instance

Insurance contract or identification number	GL 153061
Number of Individuals Covered	700
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $17,407
Total amount of fees paid to insurance company	USD $219
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,752
Amount paid for insurance broker fees	219
Insurance broker organization code?	3
Insurance broker name	ELIZABETH SCHENK

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

13866

Policy instance

Insurance contract or identification number	13866
Number of Individuals Covered	200
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $83,796
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $364,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,372
Insurance broker organization code?	3
Insurance broker name	MWL

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

Policy contract number

136-007269

Policy instance

Insurance contract or identification number	136-007269
Number of Individuals Covered	844
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $3,152
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $295,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,152
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

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

Policy contract number

VPS 326566

Policy instance

Insurance contract or identification number	VPS 326566
Number of Individuals Covered	187
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $6,404
Total amount of fees paid to insurance company	USD $122
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $39,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,404
Amount paid for insurance broker fees	122
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

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

Policy contract number

R0384024

Policy instance

Insurance contract or identification number	R0384024
Number of Individuals Covered	811
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $34,347
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $234,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,347
Insurance broker name	CREATIVE BENEFIT SOLUTIONS LLC

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

DED/CO FAMILY C

Policy instance

Insurance contract or identification number	DED/CO FAMILY C
Number of Individuals Covered	92
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $17,770
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,238
Insurance broker organization code?	3
Insurance broker name	GREG LIPOSKY

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

BUY UP OPTION

Policy instance

Insurance contract or identification number	BUY UP OPTION
Number of Individuals Covered	191
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $104,231
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $445,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,665
Insurance broker name	GREG LIPOSKY

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

Policy contract number

52389

Policy instance

Insurance contract or identification number	52389
Number of Individuals Covered	690
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $48,213
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,502
Insurance broker organization code?	3
Insurance broker name	INSURANCE CONSULTING ASSOC

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

Policy contract number

00471901

Policy instance

Insurance contract or identification number	00471901
Number of Individuals Covered	352
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $38,408
Total amount of fees paid to insurance company	USD $6,508
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $317,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,646
Insurance broker organization code?	3
Amount paid for insurance broker fees	6508
Insurance broker name	GREG LIPOSKY

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

BUY UP OPTION

Policy instance

Insurance contract or identification number	BUY UP OPTION
Number of Individuals Covered	187
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $110,414
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $461,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,202
Insurance broker organization code?	3
Insurance broker name	MWL

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

Policy contract number

52389

Policy instance

Insurance contract or identification number	52389
Number of Individuals Covered	716
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $38,553
Total amount of fees paid to insurance company	USD $5,327
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,553
Amount paid for insurance broker fees	5327
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

00471901

Policy instance

Insurance contract or identification number	00471901
Number of Individuals Covered	339
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $13,906
Total amount of fees paid to insurance company	USD $7,296
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $277,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,906
Amount paid for insurance broker fees	7296
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS, LLC -

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

DED/CO FAMILY C

Policy instance

Insurance contract or identification number	DED/CO FAMILY C
Number of Individuals Covered	80
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $16,063
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,351
Insurance broker organization code?	3
Insurance broker name	MWL

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9813411

Policy instance

Insurance contract or identification number	9813411
Number of Individuals Covered	648
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $7,911
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,911
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS, LLC -

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

Policy contract number

00471901

Policy instance

Insurance contract or identification number	00471901
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 $4,164
Total amount of fees paid to insurance company	USD $2,205
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,164
Amount paid for insurance broker fees	2205
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT SOLUTIONS

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

BUY UP OPTION

Policy instance

Insurance contract or identification number	BUY UP OPTION
Number of Individuals Covered	168
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $90,988
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $447,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,076
Insurance broker organization code?	3
Insurance broker name	MWL

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

Policy contract number

52389

Policy instance

Insurance contract or identification number	52389
Number of Individuals Covered	709
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $39,411
Total amount of fees paid to insurance company	USD $4,395
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,211,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,411
Amount paid for insurance broker fees	4395
Insurance broker organization code?	3
Insurance broker name	GREG LIPOSKY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9813411

Policy instance

Insurance contract or identification number	9813411
Number of Individuals Covered	641
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,221
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,761
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

780019

Policy instance

Insurance contract or identification number	780019
Number of Individuals Covered	556
Insurance policy start date	2011-01-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $69,120
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,390,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

36364

Policy instance

Insurance contract or identification number	36364
Number of Individuals Covered	345
Insurance policy start date	2011-01-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $27,747
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $231,255
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

780019

Policy instance

Insurance contract or identification number	780019
Number of Individuals Covered	228
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $83,795
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,482,929
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

780019

Policy instance

Insurance contract or identification number	780019
Number of Individuals Covered	188
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $20,169
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $266,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	LAFONTAINE MOTORS, INC.
Employer identification number (EIN):	382307028
NAIC Classification:	444110
NAIC Description:	Home Centers