NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN
Plan identification number	502

NBHX TRIM USA CORPORATION 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) Long-term disability cover Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

NBHX TRIM USA CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:	NBHX TRIM USA CORPORATION
Employer identification number (EIN):	382898660
NAIC Classification:	336300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01
502	2017-01-01
502	2016-01-01	BECKY A HIGBEE
502	2015-01-01	PETER J WALENTA
502	2014-01-01	PETER J WALWNTA
502	2013-01-01	PETER J WALENTIA
502	2012-01-01	NORBERT DIETERLE
502	2011-01-01	NORBERT DIETERLE
502	2010-01-01	NORBERT DIETERLE
502	2008-01-01	NORBERT DIETERLE
502	2007-01-01	NORBERT DIETERLE
502	2006-01-01	NORBERT DIETERLE
502	2005-01-01	NORBERT DIETERLE
502	2004-01-01	NORBERT DIETERLE
502	2003-01-01	NORBERT DIETERLE
502	2002-01-01	NORBERT DIETERLE
502	2001-01-01	NORBERT DIETERLE
502	2000-01-01	NORBERT DIETERLE
502	1999-01-01	NORBERT DIETERLE
502	1998-01-01	NORBERT DIETERLE
502	1997-01-01	NORBERT DIETERLE
502	1996-01-01	NORBERT DIETERLE
502	1995-01-01	NORBERT DIETERLE
502	1994-01-01	NORBERT DIETERLE
502	1993-01-01	NORBERT DIETERLE
502	1992-01-01	NORBERT DIETERLE

Plan Statistics for NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN

401k plan membership statisitcs for NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN

Measure	Date	Value
2022: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	86
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	0
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	0
2021: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	86
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	86
2020: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	263
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	184
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	184
2019: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	263
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	263
2018: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	436
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	340
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	340
Number of employers contributing to the scheme	2018-01-01	0
2017: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	411
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	440
Number of retired or separated participants receiving benefits	2017-01-01	2
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	442
2016: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	360
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	403
Number of retired or separated participants receiving benefits	2016-01-01	3
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	406
2015: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	344
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	346
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	346
2014: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	342
Number of retired or separated participants receiving benefits	2014-01-01	2
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	344
2013: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	298
Number of retired or separated participants receiving benefits	2013-01-01	1
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	299
2012: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	285
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	285
2011: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	189
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	246
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	246
2010: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	189
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	189
2008: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	91
Number of retired or separated participants receiving benefits	2008-01-01	0
Number of other retired or separated participants entitled to future benefits	2008-01-01	0
Total of all active and inactive participants	2008-01-01	91
2007: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	301
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	274
Number of retired or separated participants receiving benefits	2007-01-01	0
Number of other retired or separated participants entitled to future benefits	2007-01-01	0
Total of all active and inactive participants	2007-01-01	274
2006: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2006 401k membership
Total participants, beginning-of-year	2006-01-01	339
Total number of active participants reported on line 7a of the Form 5500	2006-01-01	301
Number of retired or separated participants receiving benefits	2006-01-01	0
Number of other retired or separated participants entitled to future benefits	2006-01-01	0
Total of all active and inactive participants	2006-01-01	301
2005: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2005 401k membership
Total participants, beginning-of-year	2005-01-01	326
Total number of active participants reported on line 7a of the Form 5500	2005-01-01	339
Number of retired or separated participants receiving benefits	2005-01-01	0
Number of other retired or separated participants entitled to future benefits	2005-01-01	0
Total of all active and inactive participants	2005-01-01	339
2004: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2004 401k membership
Total participants, beginning-of-year	2004-01-01	430
Total number of active participants reported on line 7a of the Form 5500	2004-01-01	326
Number of retired or separated participants receiving benefits	2004-01-01	0
Number of other retired or separated participants entitled to future benefits	2004-01-01	0
Total of all active and inactive participants	2004-01-01	326
2003: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2003 401k membership
Total participants, beginning-of-year	2003-01-01	522
Total number of active participants reported on line 7a of the Form 5500	2003-01-01	430
Number of retired or separated participants receiving benefits	2003-01-01	0
Number of other retired or separated participants entitled to future benefits	2003-01-01	0
Total of all active and inactive participants	2003-01-01	430
2002: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2002 401k membership
Total participants, beginning-of-year	2002-01-01	539
Total number of active participants reported on line 7a of the Form 5500	2002-01-01	522
Number of retired or separated participants receiving benefits	2002-01-01	0
Number of other retired or separated participants entitled to future benefits	2002-01-01	0
Total of all active and inactive participants	2002-01-01	522
2001: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2001 401k membership
Total participants, beginning-of-year	2001-01-01	583
Total number of active participants reported on line 7a of the Form 5500	2001-01-01	539
Number of retired or separated participants receiving benefits	2001-01-01	0
Number of other retired or separated participants entitled to future benefits	2001-01-01	0
Total of all active and inactive participants	2001-01-01	539
2000: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2000 401k membership
Total participants, beginning-of-year	2000-01-01	483
Total number of active participants reported on line 7a of the Form 5500	2000-01-01	583
Number of retired or separated participants receiving benefits	2000-01-01	0
Number of other retired or separated participants entitled to future benefits	2000-01-01	0
Total of all active and inactive participants	2000-01-01	583
1999: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1999 401k membership
Total participants, beginning-of-year	1999-01-01	371
Total number of active participants reported on line 7a of the Form 5500	1999-01-01	483
Number of retired or separated participants receiving benefits	1999-01-01	0
Number of other retired or separated participants entitled to future benefits	1999-01-01	0
Total of all active and inactive participants	1999-01-01	483
1998: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1998 401k membership
Total participants, beginning-of-year	1998-01-01	393
Total number of active participants reported on line 7a of the Form 5500	1998-01-01	371
Number of retired or separated participants receiving benefits	1998-01-01	0
Number of other retired or separated participants entitled to future benefits	1998-01-01	0
Total of all active and inactive participants	1998-01-01	371
1997: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1997 401k membership
Total participants, beginning-of-year	1997-01-01	331
Total number of active participants reported on line 7a of the Form 5500	1997-01-01	393
Number of retired or separated participants receiving benefits	1997-01-01	0
Number of other retired or separated participants entitled to future benefits	1997-01-01	0
Total of all active and inactive participants	1997-01-01	393
1996: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1996 401k membership
Total participants, beginning-of-year	1996-01-01	352
Total number of active participants reported on line 7a of the Form 5500	1996-01-01	331
Number of retired or separated participants receiving benefits	1996-01-01	0
Number of other retired or separated participants entitled to future benefits	1996-01-01	0
Total of all active and inactive participants	1996-01-01	331
1995: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1995 401k membership
Total participants, beginning-of-year	1995-01-01	355
Total number of active participants reported on line 7a of the Form 5500	1995-01-01	352
Number of retired or separated participants receiving benefits	1995-01-01	0
Number of other retired or separated participants entitled to future benefits	1995-01-01	0
Total of all active and inactive participants	1995-01-01	352
1994: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1994 401k membership
Total participants, beginning-of-year	1994-01-01	377
Total number of active participants reported on line 7a of the Form 5500	1994-01-01	355
Number of retired or separated participants receiving benefits	1994-01-01	0
Number of other retired or separated participants entitled to future benefits	1994-01-01	0
Total of all active and inactive participants	1994-01-01	355
1993: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1993 401k membership
Total participants, beginning-of-year	1993-01-01	218
Total number of active participants reported on line 7a of the Form 5500	1993-01-01	377
Number of retired or separated participants receiving benefits	1993-01-01	0
Number of other retired or separated participants entitled to future benefits	1993-01-01	0
Total of all active and inactive participants	1993-01-01	377
1992: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1992 401k membership
Total participants, beginning-of-year	1992-01-01	145
Total number of active participants reported on line 7a of the Form 5500	1992-01-01	218
Number of retired or separated participants receiving benefits	1992-01-01	0
Number of other retired or separated participants entitled to future benefits	1992-01-01	0
Total of all active and inactive participants	1992-01-01	218

Form 5500 Responses for NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN

2022: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	Yes
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION 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: NBHX TRIM USA CORPORATION 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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE 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 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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
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: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
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
2010: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2008: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Submission has been amended	No
2008-01-01	This submission is the final filing	No
2008-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-01-01	Plan is a collectively bargained plan	No
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2007: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	No
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2006: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	Submission has been amended	No
2006-01-01	This submission is the final filing	No
2006-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-01-01	Plan is a collectively bargained plan	No
2006-01-01	Plan funding arrangement – Insurance	Yes
2006-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2006-01-01	Plan benefit arrangement – Insurance	Yes
2006-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2005: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	Submission has been amended	No
2005-01-01	This submission is the final filing	No
2005-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-01-01	Plan is a collectively bargained plan	No
2005-01-01	Plan funding arrangement – Insurance	Yes
2005-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2005-01-01	Plan benefit arrangement – Insurance	Yes
2005-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2004: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2004 form 5500 responses
2004-01-01	Type of plan entity	Single employer plan
2004-01-01	Submission has been amended	No
2004-01-01	This submission is the final filing	No
2004-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-01-01	Plan is a collectively bargained plan	No
2004-01-01	Plan funding arrangement – Insurance	Yes
2004-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2004-01-01	Plan benefit arrangement – Insurance	Yes
2004-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2003: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2003 form 5500 responses
2003-01-01	Type of plan entity	Single employer plan
2003-01-01	Submission has been amended	No
2003-01-01	This submission is the final filing	No
2003-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2003-01-01	Plan is a collectively bargained plan	No
2003-01-01	Plan funding arrangement – Insurance	Yes
2003-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2003-01-01	Plan benefit arrangement – Insurance	Yes
2003-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2002: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2002 form 5500 responses
2002-01-01	Type of plan entity	Single employer plan
2002-01-01	Submission has been amended	No
2002-01-01	This submission is the final filing	No
2002-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2002-01-01	Plan is a collectively bargained plan	No
2002-01-01	Plan funding arrangement – Insurance	Yes
2002-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2002-01-01	Plan benefit arrangement – Insurance	Yes
2002-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2001: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2001 form 5500 responses
2001-01-01	Type of plan entity	Single employer plan
2001-01-01	Submission has been amended	No
2001-01-01	This submission is the final filing	No
2001-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2001-01-01	Plan is a collectively bargained plan	No
2001-01-01	Plan funding arrangement – Insurance	Yes
2001-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2001-01-01	Plan benefit arrangement – Insurance	Yes
2001-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2000: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 2000 form 5500 responses
2000-01-01	Type of plan entity	Single employer plan
2000-01-01	Submission has been amended	No
2000-01-01	This submission is the final filing	No
2000-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2000-01-01	Plan is a collectively bargained plan	No
2000-01-01	Plan funding arrangement – Insurance	Yes
2000-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2000-01-01	Plan benefit arrangement – Insurance	Yes
2000-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
1999: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1999 form 5500 responses
1999-01-01	Type of plan entity	Single employer plan
1999-01-01	Submission has been amended	No
1999-01-01	This submission is the final filing	No
1999-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1999-01-01	Plan is a collectively bargained plan	No
1999-01-01	Plan funding arrangement – Insurance	Yes
1999-01-01	Plan funding arrangement – General assets of the sponsor	Yes
1999-01-01	Plan benefit arrangement – Insurance	Yes
1999-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
1998: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1998 form 5500 responses
1998-01-01	Type of plan entity	Single employer plan
1998-01-01	Submission has been amended	No
1998-01-01	This submission is the final filing	No
1998-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1998-01-01	Plan is a collectively bargained plan	No
1998-01-01	Plan funding arrangement – Insurance	Yes
1998-01-01	Plan benefit arrangement – Insurance	Yes
1997: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1997 form 5500 responses
1997-01-01	Type of plan entity	Single employer plan
1997-01-01	Submission has been amended	No
1997-01-01	This submission is the final filing	No
1997-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1997-01-01	Plan is a collectively bargained plan	No
1997-01-01	Plan funding arrangement – Insurance	Yes
1997-01-01	Plan benefit arrangement – Insurance	Yes
1996: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1996 form 5500 responses
1996-01-01	Type of plan entity	Single employer plan
1996-01-01	Submission has been amended	No
1996-01-01	This submission is the final filing	No
1996-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1996-01-01	Plan is a collectively bargained plan	No
1996-01-01	Plan funding arrangement – Insurance	Yes
1996-01-01	Plan benefit arrangement – Insurance	Yes
1995: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1995 form 5500 responses
1995-01-01	Type of plan entity	Single employer plan
1995-01-01	Submission has been amended	No
1995-01-01	This submission is the final filing	No
1995-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1995-01-01	Plan is a collectively bargained plan	No
1995-01-01	Plan funding arrangement – Insurance	Yes
1995-01-01	Plan benefit arrangement – Insurance	Yes
1994: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1994 form 5500 responses
1994-01-01	Type of plan entity	Single employer plan
1994-01-01	Submission has been amended	No
1994-01-01	This submission is the final filing	No
1994-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1994-01-01	Plan is a collectively bargained plan	No
1994-01-01	Plan funding arrangement – Insurance	Yes
1994-01-01	Plan benefit arrangement – Insurance	Yes
1993: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1993 form 5500 responses
1993-01-01	Type of plan entity	Single employer plan
1993-01-01	Submission has been amended	No
1993-01-01	This submission is the final filing	No
1993-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1993-01-01	Plan is a collectively bargained plan	No
1993-01-01	Plan funding arrangement – Insurance	Yes
1993-01-01	Plan benefit arrangement – Insurance	Yes
1992: NBHX TRIM USA CORPORATION HEALTH AND WELFARE PLAN 1992 form 5500 responses
1992-01-01	Type of plan entity	Single employer plan
1992-01-01	First time form 5500 has been submitted	Yes
1992-01-01	Submission has been amended	No
1992-01-01	This submission is the final filing	No
1992-01-01	This return/report is a short plan year return/report (less than 12 months)	No
1992-01-01	Plan is a collectively bargained plan	No
1992-01-01	Plan funding arrangement – Insurance	Yes
1992-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30095724
Policy instance	5
Insurance contract or identification number 30095724 Number of Individuals Covered 41 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $800 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,652 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $800 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969483
Policy instance	2
Insurance contract or identification number FLX969483 Number of Individuals Covered 24 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $161 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,442 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $161 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 966277
Policy instance	3
Insurance contract or identification number LK 966277 Number of Individuals Covered 77 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970913
Policy instance	4
Insurance contract or identification number OK 970913 Number of Individuals Covered 77 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,749 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970914
Policy instance	6
Insurance contract or identification number OK 970914 Number of Individuals Covered 24 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $27 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,167 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 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00518962
Policy instance	7
Insurance contract or identification number 00518962 Number of Individuals Covered 60 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,211 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 969482
Policy instance	1
Insurance contract or identification number FLX 969482 Number of Individuals Covered 77 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,658 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SHD963440
Policy instance	9
Insurance contract or identification number SHD963440 Number of Individuals Covered 77 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,258 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	10005570
Policy instance	8
Insurance contract or identification number 10005570 Number of Individuals Covered 68 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $793,854 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970913
Policy instance	4
Insurance contract or identification number OK 970913 Number of Individuals Covered 86 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 $60 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 60 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 969482
Policy instance	1
Insurance contract or identification number FLX 969482 Number of Individuals Covered 86 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 $433 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,688 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 433 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	10005570
Policy instance	8
Insurance contract or identification number 10005570 Number of Individuals Covered 68 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $905,789 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969483
Policy instance	2
Insurance contract or identification number FLX969483 Number of Individuals Covered 29 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $190 Total amount of fees paid to insurance company USD $363 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,140 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $190 Amount paid for insurance broker fees 363 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30095724
Policy instance	5
Insurance contract or identification number 30095724 Number of Individuals Covered 47 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,291 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,669 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,291 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970914
Policy instance	6
Insurance contract or identification number OK 970914 Number of Individuals Covered 29 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $10 Total amount of fees paid to insurance company USD $43 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $249 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 Amount paid for insurance broker fees 43 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00518962
Policy instance	7
Insurance contract or identification number 00518962 Number of Individuals Covered 65 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 966277
Policy instance	3
Insurance contract or identification number LK 966277 Number of Individuals Covered 86 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 $282 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 282 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00518962
Policy instance	7
Insurance contract or identification number 00518962 Number of Individuals Covered 138 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,162 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	30095724
Policy instance	5
Insurance contract or identification number 30095724 Number of Individuals Covered 55 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,660 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,071 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,660 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970914
Policy instance	6
Insurance contract or identification number OK 970914 Number of Individuals Covered 86 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $46 Total amount of fees paid to insurance company USD $91 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46 Amount paid for insurance broker fees 91 Additional information about fees paid to insurance broker SALES AND SERVICE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 970913
Policy instance	4
Insurance contract or identification number OK 970913 Number of Individuals Covered 184 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 $192 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,631 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 192 Additional information about fees paid to insurance broker SALES AND SERVICE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 966277
Policy instance	3
Insurance contract or identification number LK 966277 Number of Individuals Covered 184 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 $1,275 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,979 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1275 Additional information about fees paid to insurance broker SALES AND SERVICE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 969482
Policy instance	1
Insurance contract or identification number FLX 969482 Number of Individuals Covered 184 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 $1,623 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,068 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1623 Additional information about fees paid to insurance broker SALES AND SERVICE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969483
Policy instance	2
Insurance contract or identification number FLX969483 Number of Individuals Covered 48 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $388 Total amount of fees paid to insurance company USD $920 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,377 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $388 Amount paid for insurance broker fees 920 Additional information about fees paid to insurance broker SALES AND SERVICE Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	12049684
Policy instance	5
Insurance contract or identification number 12049684 Number of Individuals Covered 147 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,068 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10238398
Policy instance	4
Insurance contract or identification number 10238398 Number of Individuals Covered 263 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 $793 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,735 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 793 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000
Policy instance	3
Insurance contract or identification number 400001000 Number of Individuals Covered 81 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,737 Total amount of fees paid to insurance company USD $833 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,190 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,780 Amount paid for insurance broker fees 833 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10238397
Policy instance	2
Insurance contract or identification number 10238397 Number of Individuals Covered 263 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 $990 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,961 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 990 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10238399
Policy instance	1
Insurance contract or identification number 10238399 Number of Individuals Covered 263 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 $2,228 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $61,191 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 2228 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	12049684-0896
Policy instance	1
Insurance contract or identification number 12049684-0896 Number of Individuals Covered 167 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 Welfare Benefit Premiums Paid to Carrier USD $21,359 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10238397
Policy instance	2
Insurance contract or identification number 10238397 Number of Individuals Covered 343 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,164 Total amount of fees paid to insurance company USD $12,286 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $161,418 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 12286 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AYYT
Policy instance	2
Insurance contract or identification number GLTD0AYYT Number of Individuals Covered 450 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 $5,698 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $189,794 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 Amount paid for insurance broker fees 3499 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	12049684-0896
Policy instance	1
Insurance contract or identification number 12049684-0896 Number of Individuals Covered 188 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 Welfare Benefit Premiums Paid to Carrier USD $21,524 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	R0396374
Policy instance	1
Insurance contract or identification number R0396374 Number of Individuals Covered 346 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10174473
Policy instance	3
Insurance contract or identification number 10174473 Number of Individuals Covered 346 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,103 Total amount of fees paid to insurance company USD $1,888 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $121,038 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,103 Insurance broker organization code? 3 Amount paid for insurance broker fees 1888 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9125875
Policy instance	2
Insurance contract or identification number 9125875 Number of Individuals Covered 2 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $-16 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10174473
Policy instance	3
Insurance contract or identification number 10174473 Number of Individuals Covered 343 Insurance policy start date 2014-05-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $8,936 Total amount of fees paid to insurance company USD $5,372 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $127,051 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,936 Amount paid for insurance broker fees 5372 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9125875
Policy instance	2
Insurance contract or identification number 9125875 Number of Individuals Covered 56 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $187 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,365 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $187 Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0396374
Policy instance	1
Insurance contract or identification number R0396374 Number of Individuals Covered 37 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $182 Total amount of fees paid to insurance company USD $14 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,528 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $182 Amount paid for insurance broker fees 14 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0396374/226481
Policy instance	1
Insurance contract or identification number R0396374/226481 Number of Individuals Covered 377 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $17,999 Total amount of fees paid to insurance company USD $1,990 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $153,760 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,249 Amount paid for insurance broker fees 1037 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9125875
Policy instance	2
Insurance contract or identification number 9125875 Number of Individuals Covered 77 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $5,972 Total amount of fees paid to insurance company USD $150 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,213 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,641 Amount paid for insurance broker fees 150 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name SENN, DUNN, MARSH AND ROLAND
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10174473
Policy instance	3
Insurance contract or identification number 10174473 Number of Individuals Covered 357 Insurance policy start date 2013-05-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $6,148 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $77,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,148 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	9125875
Policy instance	1
Insurance contract or identification number 9125875 Number of Individuals Covered 86 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $2,520 Total amount of fees paid to insurance company USD $83 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,001 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,520 Amount paid for insurance broker fees 83 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0396374
Policy instance	2
Insurance contract or identification number R0396374 Number of Individuals Covered 290 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $11,301 Total amount of fees paid to insurance company USD $2,473 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $90,019 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,301 Amount paid for insurance broker fees 2473 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	226481
Policy instance	3
Insurance contract or identification number 226481 Number of Individuals Covered 92 Insurance policy start date 2012-01-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $1,660 Total amount of fees paid to insurance company USD $210 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,398 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,660 Amount paid for insurance broker fees 210 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name WELLS FARGO INSURANCE SERVICES
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract number	HCL17979
Policy instance	1
Insurance contract or identification number HCL17979 Number of Individuals Covered 348 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $9,742 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $389,685 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	3
Insurance contract or identification number H22874 Number of Individuals Covered 259 Insurance policy start date 2011-06-01 Insurance policy end date 2011-08-31 Total amount of commissions paid to insurance broker USD $469 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,048 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	2
Insurance contract or identification number H22874 Number of Individuals Covered 244 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $7,239 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $84,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	1
Insurance contract or identification number H22874 Number of Individuals Covered 168 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $4,588 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $43,334 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	1
Insurance contract or identification number H22874 Number of Individuals Covered 267 Insurance policy start date 2007-06-01 Insurance policy end date 2008-05-31 Total amount of commissions paid to insurance broker USD $4,384 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $39,095 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	1
Insurance contract or identification number H22874 Number of Individuals Covered 291 Insurance policy start date 2006-06-01 Insurance policy end date 2007-05-31 Total amount of commissions paid to insurance broker USD $4,613 Total amount of fees paid to insurance company USD $522 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $43,068 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H22874
Policy instance	1
Insurance contract or identification number H22874 Number of Individuals Covered 319 Insurance policy start date 2005-06-01 Insurance policy end date 2006-05-31 Total amount of commissions paid to insurance broker USD $6,048 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $47,036 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F006266
Policy instance	2
Insurance contract or identification number F006266 Number of Individuals Covered 339 Insurance policy start date 2005-02-01 Insurance policy end date 2005-05-31 Total amount of commissions paid to insurance broker USD $3,762 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,809 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number	F006266
Policy instance	1
Insurance contract or identification number F006266 Number of Individuals Covered 339 Insurance policy start date 2004-02-01 Insurance policy end date 2005-01-31 Total amount of commissions paid to insurance broker USD $12,637 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $63,185 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	GL674323
Policy instance	1
Insurance contract or identification number GL674323 Number of Individuals Covered 411 Insurance policy start date 2004-01-01 Insurance policy end date 2004-01-31 Total amount of commissions paid to insurance broker USD $2,366 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,920 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	GL674323
Policy instance	2
Insurance contract or identification number GL674323 Number of Individuals Covered 416 Insurance policy start date 2003-01-01 Insurance policy end date 2003-12-31 Total amount of commissions paid to insurance broker USD $9,393 Total amount of fees paid to insurance company USD $150 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $81,878 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
GRAND VALLEY HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95453 )
Policy contract number	319
Policy instance	1
Insurance contract or identification number 319 Number of Individuals Covered 430 Insurance policy start date 2002-06-01 Insurance policy end date 2003-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
GRAND VALLEY HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95453 )
Policy contract number	319
Policy instance	1
Insurance contract or identification number 319 Number of Individuals Covered 522 Insurance policy start date 2001-06-01 Insurance policy end date 2002-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 522 Insurance policy start date 2001-09-01 Insurance policy end date 2002-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	3
Insurance contract or identification number 264278 Number of Individuals Covered 522 Insurance policy start date 2002-09-01 Insurance policy end date 2002-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	GL674323
Policy instance	4
Insurance contract or identification number GL674323 Number of Individuals Covered 579 Insurance policy start date 2002-01-01 Insurance policy end date 2002-12-31 Total amount of commissions paid to insurance broker USD $9,741 Total amount of fees paid to insurance company USD $150 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $90,566 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
GRAND VALLEY HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95453 )
Policy contract number	319
Policy instance	1
Insurance contract or identification number 319 Number of Individuals Covered 539 Insurance policy start date 2000-06-01 Insurance policy end date 2001-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 539 Insurance policy start date 2000-09-01 Insurance policy end date 2001-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 583 Insurance policy start date 1999-04-01 Insurance policy end date 1999-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	3
Insurance contract or identification number 264278 Number of Individuals Covered 583 Insurance policy start date 1999-09-01 Insurance policy end date 2000-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
GRAND VALLEY HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95453 )
Policy contract number	319
Policy instance	1
Insurance contract or identification number 319 Number of Individuals Covered 583 Insurance policy start date 1999-06-01 Insurance policy end date 2000-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
GRAND VALLEY HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95453 )
Policy contract number	319
Policy instance	1
Insurance contract or identification number 319 Number of Individuals Covered 483 Insurance policy start date 1998-06-01 Insurance policy end date 1999-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 483 Insurance policy start date 1998-04-01 Insurance policy end date 1999-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 483 Insurance policy start date 1998-09-01 Insurance policy end date 1999-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	3
Insurance contract or identification number 264278 Number of Individuals Covered 371 Insurance policy start date 1997-04-01 Insurance policy end date 1998-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	4
Insurance contract or identification number 260351 Number of Individuals Covered 371 Insurance policy start date 1997-09-01 Insurance policy end date 1998-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	2
Insurance contract or identification number 442 Number of Individuals Covered 371 Insurance policy start date 1998-04-01 Insurance policy end date 1998-05-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 371 Insurance policy start date 1997-04-01 Insurance policy end date 1998-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 393 Insurance policy start date 1996-04-01 Insurance policy end date 1997-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 393 Insurance policy start date 1996-09-01 Insurance policy end date 1997-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 393 Insurance policy start date 1996-04-01 Insurance policy end date 1997-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 331 Insurance policy start date 1995-04-01 Insurance policy end date 1996-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 331 Insurance policy start date 1995-04-01 Insurance policy end date 1996-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 331 Insurance policy start date 1995-09-01 Insurance policy end date 1996-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 352 Insurance policy start date 1994-09-01 Insurance policy end date 1995-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 352 Insurance policy start date 1994-04-01 Insurance policy end date 1995-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 352 Insurance policy start date 1994-04-01 Insurance policy end date 1995-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 355 Insurance policy start date 1993-04-01 Insurance policy end date 1994-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 355 Insurance policy start date 1993-09-01 Insurance policy end date 1994-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 355 Insurance policy start date 1993-04-01 Insurance policy end date 1994-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 377 Insurance policy start date 1992-09-01 Insurance policy end date 1993-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 377 Insurance policy start date 1992-04-01 Insurance policy end date 1993-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 377 Insurance policy start date 1992-04-01 Insurance policy end date 1993-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	264278
Policy instance	2
Insurance contract or identification number 264278 Number of Individuals Covered 218 Insurance policy start date 1991-04-01 Insurance policy end date 1992-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	260351
Policy instance	3
Insurance contract or identification number 260351 Number of Individuals Covered 218 Insurance policy start date 1991-09-01 Insurance policy end date 1992-08-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	442
Policy instance	1
Insurance contract or identification number 442 Number of Individuals Covered 218 Insurance policy start date 1991-04-01 Insurance policy end date 1992-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes