GREEKTOWN CASINO GROUP HEALTH PLAN 401k Plan overview

Plan Name	GREEKTOWN CASINO GROUP HEALTH PLAN
Plan identification number	501

GREEKTOWN CASINO GROUP HEALTH PLAN Benefits

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

401k Sponsoring company profile

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

Company Name:	JACK ENTERTAINMENT LLC
Employer identification number (EIN):	383337941
NAIC Classification:	713200
NAIC Description:	Gambling Industries

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GREEKTOWN CASINO GROUP HEALTH PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-01-01	MARK LAM	2021-10-08
501	2020-01-01	MARK LAM	2021-10-08
501	2020-01-01	JEANNINE EDGREN	2022-08-19
501	2019-01-01	MATTHEW RIZIK	2020-10-14	MATTHEW RIZIK	2020-10-14
501	2018-01-01	GLEN TOMASZEWSKI	2019-09-30	GLEN TOMASZEWSKI	2019-09-30
501	2017-01-01
501	2016-06-01
501	2015-06-01
501	2014-06-01
501	2013-06-01
501	2012-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2011-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2010-06-01
501	2009-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2009-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2008-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2007-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2006-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2005-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2004-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2003-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2002-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2001-06-01	CYNTHIA TACHENY - AS PRACTITIONER
501	2000-11-01	CYNTHIA TACHENY - AS PRACTITIONER

Plan Statistics for GREEKTOWN CASINO GROUP HEALTH PLAN

401k plan membership statisitcs for GREEKTOWN CASINO GROUP HEALTH PLAN

Measure	Date	Value
2020: GREEKTOWN CASINO GROUP HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	109
Number of retired or separated participants receiving benefits	2020-01-01	30
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	139
2019: GREEKTOWN CASINO GROUP HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	109
Number of retired or separated participants receiving benefits	2019-01-01	17
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	126
2018: GREEKTOWN CASINO GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,573
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,541
Number of retired or separated participants receiving benefits	2018-01-01	10
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	1,551
2017: GREEKTOWN CASINO GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,895
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,569
Number of retired or separated participants receiving benefits	2017-01-01	4
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	1,573
2016: GREEKTOWN CASINO GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	1,614
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	1,892
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	1,892
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-06-01	0
Total participants	2016-06-01	1,892
2015: GREEKTOWN CASINO GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	1,592
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	1,605
Number of retired or separated participants receiving benefits	2015-06-01	9
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	1,614
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-06-01	0
Total participants	2015-06-01	1,614
2014: GREEKTOWN CASINO GROUP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	1,624
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	1,582
Number of retired or separated participants receiving benefits	2014-06-01	10
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	1,592
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-06-01	0
Total participants	2014-06-01	1,592
2013: GREEKTOWN CASINO GROUP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	1,546
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	1,613
Number of retired or separated participants receiving benefits	2013-06-01	11
Total of all active and inactive participants	2013-06-01	1,624
Total participants	2013-06-01	1,624
2012: GREEKTOWN CASINO GROUP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	1,682
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	1,539
Number of retired or separated participants receiving benefits	2012-06-01	7
Total of all active and inactive participants	2012-06-01	1,546
Total participants	2012-06-01	1,546
2011: GREEKTOWN CASINO GROUP HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	1,749
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	1,682
Total of all active and inactive participants	2011-06-01	1,682
Total participants	2011-06-01	1,682
2010: GREEKTOWN CASINO GROUP HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year	2010-06-01	1,775
Total number of active participants reported on line 7a of the Form 5500	2010-06-01	1,749
Total of all active and inactive participants	2010-06-01	1,749
Total participants	2010-06-01	1,749
2009: GREEKTOWN CASINO GROUP HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	1,806
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	1,775
Total of all active and inactive participants	2009-06-01	1,775
Total participants	2009-06-01	1,775
2008: GREEKTOWN CASINO GROUP HEALTH PLAN 2008 401k membership
Total participants, beginning-of-year	2008-06-01	1,826
Total number of active participants reported on line 7a of the Form 5500	2008-06-01	1,806
Total of all active and inactive participants	2008-06-01	1,806
Total participants	2008-06-01	1,806
2007: GREEKTOWN CASINO GROUP HEALTH PLAN 2007 401k membership
Total participants, beginning-of-year	2007-06-01	1,847
Total number of active participants reported on line 7a of the Form 5500	2007-06-01	1,826
Total of all active and inactive participants	2007-06-01	1,826
Total participants	2007-06-01	1,826
2006: GREEKTOWN CASINO GROUP HEALTH PLAN 2006 401k membership
Total participants, beginning-of-year	2006-06-01	2,008
Total number of active participants reported on line 7a of the Form 5500	2006-06-01	1,847
Total of all active and inactive participants	2006-06-01	1,847
Total participants	2006-06-01	1,847
2005: GREEKTOWN CASINO GROUP HEALTH PLAN 2005 401k membership
Total participants, beginning-of-year	2005-06-01	2,026
Total number of active participants reported on line 7a of the Form 5500	2005-06-01	2,008
Total of all active and inactive participants	2005-06-01	2,008
Total participants	2005-06-01	2,008
2004: GREEKTOWN CASINO GROUP HEALTH PLAN 2004 401k membership
Total participants, beginning-of-year	2004-06-01	2,092
Total number of active participants reported on line 7a of the Form 5500	2004-06-01	2,026
Total of all active and inactive participants	2004-06-01	2,026
Total participants	2004-06-01	2,026
2003: GREEKTOWN CASINO GROUP HEALTH PLAN 2003 401k membership
Total participants, beginning-of-year	2003-06-01	2,268
Total number of active participants reported on line 7a of the Form 5500	2003-06-01	2,092
Total of all active and inactive participants	2003-06-01	2,092
Total participants	2003-06-01	2,092
2002: GREEKTOWN CASINO GROUP HEALTH PLAN 2002 401k membership
Total participants, beginning-of-year	2002-06-01	2,408
Total number of active participants reported on line 7a of the Form 5500	2002-06-01	2,268
Total of all active and inactive participants	2002-06-01	2,268
Total participants	2002-06-01	2,268
2001: GREEKTOWN CASINO GROUP HEALTH PLAN 2001 401k membership
Total participants, beginning-of-year	2001-06-01	3,565
Total number of active participants reported on line 7a of the Form 5500	2001-06-01	2,408
Total of all active and inactive participants	2001-06-01	2,408
Total participants	2001-06-01	2,408
2000: GREEKTOWN CASINO GROUP HEALTH PLAN 2000 401k membership
Total participants, beginning-of-year	2000-11-01	3,022
Total number of active participants reported on line 7a of the Form 5500	2000-11-01	3,565
Total of all active and inactive participants	2000-11-01	3,565
Total participants	2000-11-01	3,565

Form 5500 Responses for GREEKTOWN CASINO GROUP HEALTH PLAN

2020: GREEKTOWN CASINO GROUP HEALTH 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: GREEKTOWN CASINO GROUP HEALTH 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: GREEKTOWN CASINO GROUP HEALTH PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
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: GREEKTOWN CASINO GROUP HEALTH PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
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: GREEKTOWN CASINO GROUP HEALTH PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Multi-employer plan
2016-06-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: GREEKTOWN CASINO GROUP HEALTH PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: GREEKTOWN CASINO GROUP HEALTH PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: GREEKTOWN CASINO GROUP HEALTH PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: GREEKTOWN CASINO GROUP HEALTH PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: GREEKTOWN CASINO GROUP HEALTH PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Submission has been amended	Yes
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: GREEKTOWN CASINO GROUP HEALTH PLAN 2010 form 5500 responses
2010-06-01	Type of plan entity	Single employer plan
2010-06-01	Submission has been amended	Yes
2010-06-01	Plan funding arrangement – Insurance	Yes
2010-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-06-01	Plan benefit arrangement – Insurance	Yes
2010-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: GREEKTOWN CASINO GROUP HEALTH PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	Submission has been amended	Yes
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2008: GREEKTOWN CASINO GROUP HEALTH PLAN 2008 form 5500 responses
2008-06-01	Type of plan entity	Single employer plan
2008-06-01	Submission has been amended	Yes
2008-06-01	Plan funding arrangement – Insurance	Yes
2008-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2008-06-01	Plan benefit arrangement – Insurance	Yes
2008-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2007: GREEKTOWN CASINO GROUP HEALTH PLAN 2007 form 5500 responses
2007-06-01	Type of plan entity	Single employer plan
2007-06-01	Plan funding arrangement – Insurance	Yes
2007-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-06-01	Plan benefit arrangement – Insurance	Yes
2007-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2006: GREEKTOWN CASINO GROUP HEALTH PLAN 2006 form 5500 responses
2006-06-01	Type of plan entity	Single employer plan
2006-06-01	Submission has been amended	Yes
2006-06-01	Plan funding arrangement – Insurance	Yes
2006-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2006-06-01	Plan benefit arrangement – Insurance	Yes
2006-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2005: GREEKTOWN CASINO GROUP HEALTH PLAN 2005 form 5500 responses
2005-06-01	Type of plan entity	Single employer plan
2005-06-01	Plan funding arrangement – Insurance	Yes
2005-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2005-06-01	Plan benefit arrangement – Insurance	Yes
2005-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2004: GREEKTOWN CASINO GROUP HEALTH PLAN 2004 form 5500 responses
2004-06-01	Type of plan entity	Single employer plan
2004-06-01	Plan funding arrangement – Insurance	Yes
2004-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2004-06-01	Plan benefit arrangement – Insurance	Yes
2004-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2003: GREEKTOWN CASINO GROUP HEALTH PLAN 2003 form 5500 responses
2003-06-01	Type of plan entity	Single employer plan
2003-06-01	Plan funding arrangement – Insurance	Yes
2003-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2003-06-01	Plan benefit arrangement – Insurance	Yes
2003-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2002: GREEKTOWN CASINO GROUP HEALTH PLAN 2002 form 5500 responses
2002-06-01	Type of plan entity	Single employer plan
2002-06-01	Plan funding arrangement – Insurance	Yes
2002-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2002-06-01	Plan benefit arrangement – Insurance	Yes
2002-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2001: GREEKTOWN CASINO GROUP HEALTH PLAN 2001 form 5500 responses
2001-06-01	Type of plan entity	Single employer plan
2001-06-01	Plan funding arrangement – Insurance	Yes
2001-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2001-06-01	Plan benefit arrangement – Insurance	Yes
2001-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2000: GREEKTOWN CASINO GROUP HEALTH PLAN 2000 form 5500 responses
2000-11-01	Type of plan entity	Single employer plan
2000-11-01	First time form 5500 has been submitted	Yes
2000-11-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2000-11-01	Plan funding arrangement – Insurance	Yes
2000-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4114-00
Policy instance	3
Insurance contract or identification number 4114-00 Number of Individuals Covered 20 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 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 $4,571 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	ADDS08900
Policy instance	2
Insurance contract or identification number ADDS08900 Number of Individuals Covered 109 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $69 Total amount of fees paid to insurance company USD $0 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 ACCIDENTAL DEATH & 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 $688 Commission paid to Insurance Broker USD $69 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker N/A Insurance broker organization code? 3 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	681152G
Policy instance	1
Insurance contract or identification number 681152G Number of Individuals Covered 109 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 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 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 $8,462 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4540183
Policy instance	4
Insurance contract or identification number E4540183 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $84 Total amount of fees paid to insurance company USD $0 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 WORKSITE 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 $866 Commission paid to Insurance Broker USD $7 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker N/A Insurance broker organization code? 3 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4540183
Policy instance	3
Insurance contract or identification number E4540183 Number of Individuals Covered 8 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,084 Total amount of fees paid to insurance company USD $98 Other welfare benefits provided VOLUNTARY WORKSITE BENEFITS Welfare Benefit Premiums Paid to Carrier USD $7,059 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $472 Amount paid for insurance broker fees 13 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4114-00
Policy instance	1
Insurance contract or identification number 4114-00 Number of Individuals Covered 246 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,417 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	681152G
Policy instance	2
Insurance contract or identification number 681152G Number of Individuals Covered 109 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $985,270 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	ADDS08900
Policy instance	4
Insurance contract or identification number ADDS08900 Number of Individuals Covered 109 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,920 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $19,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,920 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4540183
Policy instance	4
Insurance contract or identification number E4540183 Number of Individuals Covered 11 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,063 Total amount of fees paid to insurance company USD $389 Other welfare benefits provided VOLUNTARY WORKSITE BENEFITS Welfare Benefit Premiums Paid to Carrier USD $10,454 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $836 Insurance broker organization code? 3 Amount paid for insurance broker fees 91 Additional information about fees paid to insurance broker FEES PAID
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4114-00
Policy instance	1
Insurance contract or identification number 4114-00 Number of Individuals Covered 314 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $562 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,193 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $562 Insurance broker organization code? 3
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	2
Insurance contract or identification number 4010-00 Number of Individuals Covered 2565 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,012 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $99,631 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,012 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	681152G
Policy instance	3
Insurance contract or identification number 681152G Number of Individuals Covered 1541 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $118,893 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,323,882 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $118,893 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS08900
Policy instance	5
Insurance contract or identification number ADDS08900 Number of Individuals Covered 1541 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,532 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $25,320 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,532 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	6
Insurance contract or identification number E7822521 Number of Individuals Covered 715 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $160,576 Total amount of fees paid to insurance company USD $21,347 Other welfare benefits provided VOLUNTARY WORKSITE BENEFITS Welfare Benefit Premiums Paid to Carrier USD $959,896 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,953 Insurance broker organization code? 3 Amount paid for insurance broker fees 4101 Additional information about fees paid to insurance broker FEES PAID
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4114-00
Policy instance	1
Insurance contract or identification number 4114-00 Number of Individuals Covered 360 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $391 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,143 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $391 Insurance broker organization code? 3 Insurance broker name KAPNICK INSURANCE GROUP
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	2
Insurance contract or identification number 4010-00 Number of Individuals Covered 2665 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,201 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $104,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,201 Insurance broker organization code? 3 Insurance broker name KAPNICK INSURANCE GROUP
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	3
Insurance contract or identification number 7599 Number of Individuals Covered 3326 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $21,491 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,491 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403185
Policy instance	4
Insurance contract or identification number 403185 Number of Individuals Covered 13 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,414 Total amount of fees paid to insurance company USD $322 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,414 Amount paid for insurance broker fees 322 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403184
Policy instance	5
Insurance contract or identification number 403184 Number of Individuals Covered 1569 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $286,354 Total amount of fees paid to insurance company USD $38,181 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,909,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $286,354 Amount paid for insurance broker fees 38181 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	GREEKTOWNCASINO
Policy instance	5
Insurance contract or identification number GREEKTOWNCASINO Number of Individuals Covered 2873 Insurance policy start date 2015-06-01 Insurance policy end date 2016-05-31 Total amount of commissions paid to insurance broker USD $5,753 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $141,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,753 Insurance broker organization code? 3 Insurance broker name KAPNICK INSURANCE GROUP
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	4
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 20 Insurance policy start date 2015-06-01 Insurance policy end date 2016-05-31 Total amount of commissions paid to insurance broker USD $5,591 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $125,969 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,591 Insurance broker organization code? 3 Insurance broker name STEPHEN PECK
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	3
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 201 Insurance policy start date 2015-06-01 Insurance policy end date 2016-05-31 Total amount of commissions paid to insurance broker USD $33,281 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $771,492 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,281 Insurance broker organization code? 3 Insurance broker name STEPHEN PECK
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	10000890
Policy instance	2
Insurance contract or identification number 10000890 Number of Individuals Covered 978 Insurance policy start date 2015-06-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $47,155 Welfare Benefit Premiums Paid to Carrier USD $3,484,204 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,155 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	1
Insurance contract or identification number 7599 Number of Individuals Covered 3285 Insurance policy start date 2015-06-01 Insurance policy end date 2016-05-31 Total amount of commissions paid to insurance broker USD $28,996 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,996 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403184
Policy instance	6
Insurance contract or identification number 403184 Number of Individuals Covered 1589 Insurance policy start date 2015-06-01 Insurance policy end date 2016-06-01 Total amount of commissions paid to insurance broker USD $179,286 Total amount of fees paid to insurance company USD $21,830 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD & D Welfare Benefit Premiums Paid to Carrier USD $1,195,242 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $179,286 Amount paid for insurance broker fees 21830 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403184
Policy instance	6
Insurance contract or identification number 403184 Number of Individuals Covered 1580 Insurance policy start date 2014-06-01 Insurance policy end date 2015-06-01 Total amount of commissions paid to insurance broker USD $194,338 Total amount of fees paid to insurance company USD $44,982 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $1,343,994 Commission paid to Insurance Broker USD $194,338 Amount paid for insurance broker fees 44982 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	10000890
Policy instance	2
Insurance contract or identification number 10000890 Number of Individuals Covered 1004 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $52,616 Welfare Benefit Premiums Paid to Carrier USD $4,582,808 Commission paid to Insurance Broker USD $52,616 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	4
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 33 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $3,257 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $115,696
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	3
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 145 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $19,941 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $561,288
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	GREEKTOWNCASINO
Policy instance	5
Insurance contract or identification number GREEKTOWNCASINO Number of Individuals Covered 1537 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $4,602 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $96,076 Commission paid to Insurance Broker USD $4,602 Insurance broker organization code? 3 Insurance broker name KAPNICK INSURANCE GROUP
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	1
Insurance contract or identification number 7599 Number of Individuals Covered 3156 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $10,643 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $10,643 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	0007599
Policy instance	1
Insurance contract or identification number 0007599 Number of Individuals Covered 3326 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $22,242 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $22,242 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	3
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1613 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $10,380 Total amount of fees paid to insurance company USD $7,007 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $129,748 Commission paid to Insurance Broker USD $10,380 Amount paid for insurance broker fees 7007 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	8
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 25 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $3,905 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $82,000
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	2
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1552 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $17,101 Total amount of fees paid to insurance company USD $8,750 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $213,757 Commission paid to Insurance Broker USD $17,101 Amount paid for insurance broker fees 8750 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403184
Policy instance	12
Insurance contract or identification number 403184 Number of Individuals Covered 1552 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $34,934 Total amount of fees paid to insurance company USD $9,316 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $232,896 Commission paid to Insurance Broker USD $34,934 Amount paid for insurance broker fees 9316 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	11
Insurance contract or identification number E7822521 Number of Individuals Covered 827 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $92,603 Total amount of fees paid to insurance company USD $32,032 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $653,927 Commission paid to Insurance Broker USD $36,261 Amount paid for insurance broker fees 25117 Additional information about fees paid to insurance broker FEES AND OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name PATRICIA REED
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8460446
Policy instance	10
Insurance contract or identification number 8460446 Number of Individuals Covered 709 Insurance policy start date 2013-03-01 Insurance policy end date 2014-03-01 Total amount of commissions paid to insurance broker USD $11,689 Total amount of fees paid to insurance company USD $562 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $139,032 Commission paid to Insurance Broker USD $10,400 Insurance broker organization code? 3 Amount paid for insurance broker fees 562 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name MARLENE GARLAND-HILL
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	9
Insurance contract or identification number 4010-00 Number of Individuals Covered 1518 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $4,511 Total amount of fees paid to insurance company USD $2,500 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $103,554 Commission paid to Insurance Broker USD $4,511 Amount paid for insurance broker fees 2500 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK INSURANCE GROUP
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	403185
Policy instance	13
Insurance contract or identification number 403185 Number of Individuals Covered 33 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $4,051 Total amount of fees paid to insurance company USD $1,080 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $27,005 Commission paid to Insurance Broker USD $4,051 Amount paid for insurance broker fees 1080 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	5
Insurance contract or identification number GUG0287F Number of Individuals Covered 1101 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $14,104 Total amount of fees paid to insurance company USD $8,750 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $176,305 Commission paid to Insurance Broker USD $14,104 Amount paid for insurance broker fees 8750 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	4
Insurance contract or identification number GUC0287F Number of Individuals Covered 49 Insurance policy start date 2013-06-01 Insurance policy end date 2014-06-01 Total amount of commissions paid to insurance broker USD $1,749 Total amount of fees paid to insurance company USD $1,270 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,860 Commission paid to Insurance Broker USD $1,749 Amount paid for insurance broker fees 1270 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	10000890
Policy instance	6
Insurance contract or identification number 10000890 Number of Individuals Covered 1047 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $39,609 Welfare Benefit Premiums Paid to Carrier USD $5,117,596 Commission paid to Insurance Broker USD $39,609 Insurance broker organization code? 3 Insurance broker name KAPNICK & COMPANY, INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	7
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 166 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $28,033 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $588,651
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	11
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1453 Insurance policy start date 2012-06-01 Insurance policy end date 2013-06-01 Total amount of commissions paid to insurance broker USD $38,851 Total amount of fees paid to insurance company USD $7,813 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $298,851 Commission paid to Insurance Broker USD $11,743 Amount paid for insurance broker fees 7813 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC., INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	10
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 24 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $2,875 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $70,550
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8460446
Policy instance	9
Insurance contract or identification number 8460446 Number of Individuals Covered 886 Insurance policy start date 2012-06-01 Insurance policy end date 2013-06-01 Total amount of commissions paid to insurance broker USD $35,692 Total amount of fees paid to insurance company USD $592 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $181,134 Commission paid to Insurance Broker USD $33,805 Amount paid for insurance broker fees 35 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MARLENE GARLAND-HILL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	8
Insurance contract or identification number GUG0287F Number of Individuals Covered 1102 Insurance policy start date 2012-06-01 Insurance policy end date 2013-06-01 Total amount of commissions paid to insurance broker USD $76,598 Total amount of fees paid to insurance company USD $8,525 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $589,218 Commission paid to Insurance Broker USD $22,829 Amount paid for insurance broker fees 8525 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC., INC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	GREEKTOWN
Policy instance	7
Insurance contract or identification number GREEKTOWN Number of Individuals Covered 3806 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $3,347 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $157,064 Commission paid to Insurance Broker USD $1,822 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	6
Insurance contract or identification number E7822521 Number of Individuals Covered 785 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $111,561 Total amount of fees paid to insurance company USD $6,428 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $681,394 Commission paid to Insurance Broker USD $42,628 Amount paid for insurance broker fees 52 Additional information about fees paid to insurance broker BONUSES AND NON-CASH INCENTIVES Insurance broker organization code? 3 Insurance broker name PATRICIA REED
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	0007599
Policy instance	5
Insurance contract or identification number 0007599 Number of Individuals Covered 3274 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $21,313 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $13,086 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	4
Insurance contract or identification number GUC0287F Number of Individuals Covered 34 Insurance policy start date 2012-06-01 Insurance policy end date 2013-06-01 Total amount of commissions paid to insurance broker USD $5,314 Total amount of fees paid to insurance company USD $1,058 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $40,874 Commission paid to Insurance Broker USD $1,634 Amount paid for insurance broker fees 1058 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC., INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	3
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1539 Insurance policy start date 2012-06-01 Insurance policy end date 2013-06-01 Total amount of commissions paid to insurance broker USD $33,695 Total amount of fees paid to insurance company USD $7,102 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $259,197 Commission paid to Insurance Broker USD $10,222 Amount paid for insurance broker fees 7102 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC., INC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	2
Insurance contract or identification number 1-32117 Number of Individuals Covered 1013 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $52,411 Welfare Benefit Premiums Paid to Carrier USD $4,490,544 Commission paid to Insurance Broker USD $52,411 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	1
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 155 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $29,129 Health Insurance Welfare Benefit Yes Other welfare benefits provided HEARING Welfare Benefit Premiums Paid to Carrier USD $515,316
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	4
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1602 Insurance policy start date 2011-06-01 Insurance policy end date 2012-06-01 Total amount of commissions paid to insurance broker USD $58,200 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $447,691
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	3
Insurance contract or identification number 7599 Number of Individuals Covered 3295 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $22,641 Dental Insurance Welfare Benefit Yes
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	12
Insurance contract or identification number E7822521 Number of Individuals Covered 713 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $123,682 Total amount of fees paid to insurance company USD $9,341 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $622,061
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	2
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 22 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $4,511 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $90,670
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	5
Insurance contract or identification number 1-32117 Number of Individuals Covered 990 Insurance policy start date 2010-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $50,081 Welfare Benefit Premiums Paid to Carrier USD $3,989,549
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	6
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1682 Insurance policy start date 2011-06-01 Insurance policy end date 2012-06-01 Total amount of commissions paid to insurance broker USD $35,626 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $274,041
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0001
Policy instance	7
Insurance contract or identification number 00137172/0001 Number of Individuals Covered 0 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $2,874 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $57,476
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	8
Insurance contract or identification number 4010-00 Number of Individuals Covered 1578 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $105,833
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	9
Insurance contract or identification number GUC0287F Number of Individuals Covered 37 Insurance policy start date 2011-06-01 Insurance policy end date 2012-06-01 Total amount of commissions paid to insurance broker USD $5,521 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $42,465
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8460446
Policy instance	10
Insurance contract or identification number 8460446 Number of Individuals Covered 935 Insurance policy start date 2011-06-01 Insurance policy end date 2012-06-01 Total amount of commissions paid to insurance broker USD $35,623 Total amount of fees paid to insurance company USD $942 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $178,178
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	11
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 187 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $22,643 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $668,661
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	1
Insurance contract or identification number GUG0287F Number of Individuals Covered 1266 Insurance policy start date 2011-06-01 Insurance policy end date 2012-06-01 Total amount of commissions paid to insurance broker USD $86,619 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $666,298
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	5
Insurance contract or identification number GUC0287F Number of Individuals Covered 40 Insurance policy start date 2010-06-01 Insurance policy end date 2011-06-01 Total amount of commissions paid to insurance broker USD $6,523 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $46,607 Commission paid to Insurance Broker USD $6,523 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	4
Insurance contract or identification number 1-32117 Number of Individuals Covered 1058 Insurance policy start date 2009-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $48,272 Welfare Benefit Premiums Paid to Carrier USD $3,636,524 Commission paid to Insurance Broker USD $48,272 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	6
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 249 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $693,628
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	3
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1749 Insurance policy start date 2010-06-01 Insurance policy end date 2011-06-01 Total amount of commissions paid to insurance broker USD $36,689 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $286,067 Commission paid to Insurance Broker USD $36,689 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0001
Policy instance	2
Insurance contract or identification number 00137172/0001 Number of Individuals Covered 46 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $5,485 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $111,058
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	7
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1624 Insurance policy start date 2010-06-01 Insurance policy end date 2011-06-01 Total amount of commissions paid to insurance broker USD $56,805 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $475,683 Commission paid to Insurance Broker USD $56,805 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	13
Insurance contract or identification number 4010-00 Number of Individuals Covered 1625 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $125,861
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	8
Insurance contract or identification number GUG0287F Number of Individuals Covered 1279 Insurance policy start date 2010-06-01 Insurance policy end date 2011-06-01 Total amount of commissions paid to insurance broker USD $68,853 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $626,290 Commission paid to Insurance Broker USD $68,853 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0004
Policy instance	9
Insurance contract or identification number 00137172/0004 Number of Individuals Covered 0 Insurance policy start date 2010-06-01 Insurance policy end date 2011-06-01 Total amount of commissions paid to insurance broker USD $90 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,816
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8460446
Policy instance	10
Insurance contract or identification number 8460446 Number of Individuals Covered 787 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $20,462 Total amount of fees paid to insurance company USD $775 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $176,234 Commission paid to Insurance Broker USD $6,836 Amount paid for insurance broker fees 66 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name CUSTOM BENEFIT PROGRAMS, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	11
Insurance contract or identification number E7822521 Number of Individuals Covered 680 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $120,372 Total amount of fees paid to insurance company USD $15,973 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $567,482 Commission paid to Insurance Broker USD $43,745 Amount paid for insurance broker fees 489 Additional information about fees paid to insurance broker FEES AND OTHER COMPENSATION Insurance broker organization code? 3 Insurance broker name WAYNE GUZMAN
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	1
Insurance contract or identification number 7599 Number of Individuals Covered 3569 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $21,529 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $21,529 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	12
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 23 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $3,156 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $64,087
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0003
Policy instance	12
Insurance contract or identification number 00137172/0003 Number of Individuals Covered 20 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $3,321 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $69,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	2
Insurance contract or identification number GUG0287F Number of Individuals Covered 1362 Insurance policy start date 2009-06-01 Insurance policy end date 2010-06-01 Total amount of commissions paid to insurance broker USD $53,291 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $608,609 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,291 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	3
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1775 Insurance policy start date 2009-06-01 Insurance policy end date 2010-06-01 Total amount of commissions paid to insurance broker USD $24,681 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $282,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,681 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	4
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1703 Insurance policy start date 2009-06-01 Insurance policy end date 2010-06-01 Total amount of commissions paid to insurance broker USD $42,304 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $476,925 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,304 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT ASSOC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	5
Insurance contract or identification number 7599 Number of Individuals Covered 3531 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $24,523 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,523 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	6
Insurance contract or identification number E7822521 Number of Individuals Covered 610 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $67,475 Total amount of fees paid to insurance company USD $6,284 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $482,349 Commission paid to Insurance Broker USD $24,237 Insurance broker organization code? 3 Amount paid for insurance broker fees 4043 Additional information about fees paid to insurance broker FEES AND OTHER COMPENSATION Insurance broker name PATRICIA REED
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	7
Insurance contract or identification number GUC0287F Number of Individuals Covered 46 Insurance policy start date 2009-06-01 Insurance policy end date 2010-06-01 Total amount of commissions paid to insurance broker USD $4,587 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,064 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,587 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	8
Insurance contract or identification number 4010-00 Number of Individuals Covered 1632 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $105,135 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	11
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 205 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $540,107 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8460446
Policy instance	10
Insurance contract or identification number 8460446 Number of Individuals Covered 807 Insurance policy start date 2009-06-01 Insurance policy end date 2010-06-01 Total amount of commissions paid to insurance broker USD $18,690 Total amount of fees paid to insurance company USD $808 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $143,631 Commission paid to Insurance Broker USD $3,769 Insurance broker organization code? 3 Amount paid for insurance broker fees 808 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name CUSTOM BENEFIT PROGRAMS, INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0001
Policy instance	1
Insurance contract or identification number 00137172/0001 Number of Individuals Covered 53 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $6,734 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $141,769 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	1-32117
Policy instance	9
Insurance contract or identification number 1-32117 Number of Individuals Covered 1024 Insurance policy start date 2008-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $47,918 Welfare Benefit Premiums Paid to Carrier USD $3,568,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,918 Insurance broker name PATTERSON BRYANT GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	4
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1599 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $50,261 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $498,261
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	5
Insurance contract or identification number 4010-00 Number of Individuals Covered 1544 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $117,202
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0287F
Policy instance	6
Insurance contract or identification number GUG 0287F Number of Individuals Covered 1276 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $53,090 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $527,976
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	8
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 94 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,246
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	9
Insurance contract or identification number 4010-00 Number of Individuals Covered 1544 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $117,202
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	7
Insurance contract or identification number GUC0287F Number of Individuals Covered 48 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $7,698 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $67,262
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	5
Insurance contract or identification number E7822521 Number of Individuals Covered 479 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $53,239 Total amount of fees paid to insurance company USD $10,171 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $247,472
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	4
Insurance contract or identification number 7599 Number of Individuals Covered 3516 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $22,179 Dental Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	2
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1599 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $50,261 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $498,261
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	9
Insurance contract or identification number 7599 Number of Individuals Covered 3516 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $22,179 Dental Insurance Welfare Benefit Yes
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	7
Insurance contract or identification number 1-32117 Number of Individuals Covered 998 Insurance policy start date 2007-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $53,987 Welfare Benefit Premiums Paid to Carrier USD $3,473,765 Commission paid to Insurance Broker USD $53,987 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0001
Policy instance	3
Insurance contract or identification number 00137172/0001 Number of Individuals Covered 31 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $5,402 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $113,717
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	1
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1806 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $26,265 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $237,150
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	10
Insurance contract or identification number 7599 Number of Individuals Covered 3516 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $22,179 Dental Insurance Welfare Benefit Yes Commission paid to Insurance Broker USD $22,179 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	9
Insurance contract or identification number GUC0287F Number of Individuals Covered 48 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $7,698 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $67,262 Commission paid to Insurance Broker USD $7,698 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	8
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1599 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $50,261 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $498,261 Commission paid to Insurance Broker USD $50,261 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0001
Policy instance	6
Insurance contract or identification number 00137172/0001 Number of Individuals Covered 31 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $5,402 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $113,717
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number	00137172/0002
Policy instance	5
Insurance contract or identification number 00137172/0002 Number of Individuals Covered 94 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,246
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	4
Insurance contract or identification number 4010-00 Number of Individuals Covered 1544 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $117,202
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	10
Insurance contract or identification number 1-32117 Number of Individuals Covered 998 Insurance policy start date 2007-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $53,987 Welfare Benefit Premiums Paid to Carrier USD $3,473,765
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	3
Insurance contract or identification number E7822521 Number of Individuals Covered 479 Insurance policy start date 2008-06-01 Insurance policy end date 2009-05-31 Total amount of commissions paid to insurance broker USD $53,239 Total amount of fees paid to insurance company USD $10,171 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $247,472 Commission paid to Insurance Broker USD $19,052 Insurance broker organization code? 3 Amount paid for insurance broker fees 4233 Additional information about fees paid to insurance broker FEES AND OTHER COMPENSATION Insurance broker name GEORGE T. NASSER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	2
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1806 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $26,265 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $237,150 Commission paid to Insurance Broker USD $26,265 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG 0287F
Policy instance	1
Insurance contract or identification number GUG 0287F Number of Individuals Covered 1276 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $53,090 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $527,976 Commission paid to Insurance Broker USD $53,090 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	2
Insurance contract or identification number GUC0287F Number of Individuals Covered 48 Insurance policy start date 2008-06-01 Insurance policy end date 2009-06-01 Total amount of commissions paid to insurance broker USD $7,698 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $67,262
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	7
Insurance contract or identification number 7599 Number of Individuals Covered 895 Insurance policy start date 2007-01-01 Insurance policy end date 2007-12-31 Total amount of commissions paid to insurance broker USD $4,813 Dental Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0287F
Policy instance	5
Insurance contract or identification number GUC0287F Number of Individuals Covered 88 Insurance policy start date 2007-06-01 Insurance policy end date 2008-06-01 Total amount of commissions paid to insurance broker USD $8,973 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $63,453 Commission paid to Insurance Broker USD $8,973 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	4
Insurance contract or identification number 1-32117 Number of Individuals Covered 1122 Insurance policy start date 2006-06-01 Insurance policy end date 2008-05-31 Total amount of commissions paid to insurance broker USD $48,019 Welfare Benefit Premiums Paid to Carrier USD $2,359,724 Commission paid to Insurance Broker USD $48,019 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	3
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1826 Insurance policy start date 2007-06-01 Insurance policy end date 2008-06-01 Total amount of commissions paid to insurance broker USD $32,840 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $253,696 Commission paid to Insurance Broker USD $32,840 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	2
Insurance contract or identification number GUG0287F Number of Individuals Covered 1228 Insurance policy start date 2007-06-01 Insurance policy end date 2008-06-01 Total amount of commissions paid to insurance broker USD $63,007 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $553,213 Commission paid to Insurance Broker USD $63,007 Insurance broker organization code? 3 Insurance broker name PATRTERSON-BRYANT ASSOC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	1
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1758 Insurance policy start date 2007-06-01 Insurance policy end date 2008-06-01 Total amount of commissions paid to insurance broker USD $59,291 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $506,757 Commission paid to Insurance Broker USD $59,291 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT ASSOC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	6
Insurance contract or identification number 4010-00 Number of Individuals Covered 1742 Insurance policy start date 2007-06-01 Insurance policy end date 2008-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $122,556
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	2
Insurance contract or identification number 3399 Number of Individuals Covered 0 Insurance policy start date 2006-01-31 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $5,079 Dental Insurance Welfare Benefit Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	5
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1847 Insurance policy start date 2006-06-01 Insurance policy end date 2007-06-01 Total amount of commissions paid to insurance broker USD $32,439 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $249,638
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	4
Insurance contract or identification number 4010-00 Number of Individuals Covered 1980 Insurance policy start date 2006-06-01 Insurance policy end date 2007-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $148,098
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	3
Insurance contract or identification number 7599 Number of Individuals Covered 3844 Insurance policy start date 2006-01-31 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $16,170 Dental Insurance Welfare Benefit Yes
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	5
Insurance contract or identification number 1-32117 Number of Individuals Covered 1092 Insurance policy start date 2005-06-01 Insurance policy end date 2007-05-31 Total amount of commissions paid to insurance broker USD $45,884 Welfare Benefit Premiums Paid to Carrier USD $3,126,711 Commission paid to Insurance Broker USD $45,884 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	1
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1799 Insurance policy start date 2006-06-01 Insurance policy end date 2007-06-01 Total amount of commissions paid to insurance broker USD $66,232 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $515,403
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0287F
Policy instance	4
Insurance contract or identification number GLUG0287F Number of Individuals Covered 1847 Insurance policy start date 2006-06-01 Insurance policy end date 2007-06-01 Total amount of commissions paid to insurance broker USD $32,439 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $249,638 Commission paid to Insurance Broker USD $32,439 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	3
Insurance contract or identification number 3399 Number of Individuals Covered 0 Insurance policy start date 2006-01-31 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $5,079 Dental Insurance Welfare Benefit Yes
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7599
Policy instance	2
Insurance contract or identification number 7599 Number of Individuals Covered 3844 Insurance policy start date 2006-01-31 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $16,170 Dental Insurance Welfare Benefit Yes
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	1
Insurance contract or identification number 4010-00 Number of Individuals Covered 1980 Insurance policy start date 2006-06-01 Insurance policy end date 2007-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $148,098
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	6
Insurance contract or identification number 1-32117 Number of Individuals Covered 1092 Insurance policy start date 2005-06-01 Insurance policy end date 2007-05-31 Total amount of commissions paid to insurance broker USD $45,884 Welfare Benefit Premiums Paid to Carrier USD $3,126,711
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0287F
Policy instance	7
Insurance contract or identification number GUG0287F Number of Individuals Covered 0 Insurance policy start date 2006-06-01 Insurance policy end date 2007-06-01 Total amount of commissions paid to insurance broker USD $69,520 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $556,504 Commission paid to Insurance Broker USD $69,520 Insurance broker organization code? 3 Insurance broker name PATTERSON-BRYANT ASSOC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7822521
Policy instance	6
Insurance contract or identification number E7822521 Number of Individuals Covered 448 Insurance policy start date 2006-06-01 Insurance policy end date 2007-05-31 Total amount of commissions paid to insurance broker USD $43,706 Total amount of fees paid to insurance company USD $4,220 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $155,695 Commission paid to Insurance Broker USD $16,090 Insurance broker organization code? 3 Amount paid for insurance broker fees 1611 Additional information about fees paid to insurance broker FEES AND OTHER COMPENSATION Insurance broker name ALICE GIBSON
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0287F
Policy instance	8
Insurance contract or identification number GLTD0287F Number of Individuals Covered 1799 Insurance policy start date 2006-06-01 Insurance policy end date 2007-06-01 Total amount of commissions paid to insurance broker USD $66,232 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $515,403 Commission paid to Insurance Broker USD $66,232 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT ASSOC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	1
Insurance contract or identification number 4010-00 Number of Individuals Covered 2050 Insurance policy start date 2005-06-01 Insurance policy end date 2006-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $133,156
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	5
Insurance contract or identification number 3399 Number of Individuals Covered 4138 Insurance policy start date 2005-01-31 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $58,887 Dental Insurance Welfare Benefit Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	568910
Policy instance	4
Insurance contract or identification number 568910 Number of Individuals Covered 2008 Insurance policy start date 2005-01-01 Insurance policy end date 2006-06-01 Total amount of commissions paid to insurance broker USD $217,654 Total amount of fees paid to insurance company USD $3,935 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,037,980 Commission paid to Insurance Broker USD $217,654 Insurance broker organization code? 3 Amount paid for insurance broker fees 3935 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name DENNIS LANE & ASSOCIATES, INC.
ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )
Policy contract number	1-32117
Policy instance	3
Insurance contract or identification number 1-32117 Number of Individuals Covered 1089 Insurance policy start date 2004-06-01 Insurance policy end date 2006-05-31 Total amount of commissions paid to insurance broker USD $33,950 Welfare Benefit Premiums Paid to Carrier USD $2,740,853 Commission paid to Insurance Broker USD $33,950 Insurance broker organization code? 3 Insurance broker name PATTERSON BRYANT GROUP
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7521
Policy instance	2
Insurance contract or identification number 7521 Number of Individuals Covered 0 Insurance policy start date 2005-01-31 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $3,238 Dental Insurance Welfare Benefit Yes
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	2
Insurance contract or identification number 4010-00 Number of Individuals Covered 2026 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $134,356
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7521
Policy instance	3
Insurance contract or identification number 7521 Number of Individuals Covered 295 Insurance policy start date 2004-01-31 Insurance policy end date 2004-12-31 Total amount of commissions paid to insurance broker USD $6,731 Dental Insurance Welfare Benefit Yes
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	4
Insurance contract or identification number 3399 Number of Individuals Covered 3748 Insurance policy start date 2004-01-31 Insurance policy end date 2004-12-31 Total amount of commissions paid to insurance broker USD $81,117 Dental Insurance Welfare Benefit Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	568910
Policy instance	1
Insurance contract or identification number 568910 Number of Individuals Covered 2092 Insurance policy start date 2004-01-01 Insurance policy end date 2005-01-01 Total amount of commissions paid to insurance broker USD $231,416 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,587,260 Commission paid to Insurance Broker USD $231,416 Insurance broker organization code? 3 Insurance broker name DENNIS LANE & ASSOCIATES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	568910
Policy instance	1
Insurance contract or identification number 568910 Number of Individuals Covered 2268 Insurance policy start date 2003-01-01 Insurance policy end date 2004-01-01 Total amount of commissions paid to insurance broker USD $178,308 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,440,582 Commission paid to Insurance Broker USD $178,308 Insurance broker organization code? 3 Insurance broker name DENNIS LANE & ASSOCIATES, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	2
Insurance contract or identification number 3399 Number of Individuals Covered 4036 Insurance policy start date 2003-01-31 Insurance policy end date 2003-12-31 Total amount of commissions paid to insurance broker USD $82,717 Dental Insurance Welfare Benefit Yes
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	3
Insurance contract or identification number 4010-00 Number of Individuals Covered 2024 Insurance policy start date 2003-06-01 Insurance policy end date 2004-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $141,204
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7521
Policy instance	4
Insurance contract or identification number 7521 Number of Individuals Covered 292 Insurance policy start date 2003-01-31 Insurance policy end date 2003-12-31 Total amount of commissions paid to insurance broker USD $6,672 Dental Insurance Welfare Benefit Yes
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	7521
Policy instance	2
Insurance contract or identification number 7521 Number of Individuals Covered 278 Insurance policy start date 2002-01-31 Insurance policy end date 2002-12-31 Total amount of commissions paid to insurance broker USD $1,773 Dental Insurance Welfare Benefit Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	568910
Policy instance	3
Insurance contract or identification number 568910 Number of Individuals Covered 2408 Insurance policy start date 2002-06-01 Insurance policy end date 2003-01-01 Total amount of commissions paid to insurance broker USD $51,346 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $386,391 Commission paid to Insurance Broker USD $51,346 Insurance broker organization code? 3 Insurance broker name DENNIS LANE & ASSOCIATES, INC.
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	1
Insurance contract or identification number 4010-00 Number of Individuals Covered 2299 Insurance policy start date 2002-06-01 Insurance policy end date 2003-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $125,506
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	4
Insurance contract or identification number 3399 Number of Individuals Covered 4127 Insurance policy start date 2002-01-31 Insurance policy end date 2002-12-31 Total amount of commissions paid to insurance broker USD $64,711 Dental Insurance Welfare Benefit Yes
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	1
Insurance contract or identification number 4010-00 Number of Individuals Covered 1825 Insurance policy start date 2001-06-01 Insurance policy end date 2002-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $91,600
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	2
Insurance contract or identification number 3399 Number of Individuals Covered 3477 Insurance policy start date 2001-01-31 Insurance policy end date 2001-12-31 Total amount of commissions paid to insurance broker USD $7,072 Dental Insurance Welfare Benefit Yes
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number	3399
Policy instance	2
Insurance contract or identification number 3399 Number of Individuals Covered 488 Insurance policy start date 2000-01-31 Insurance policy end date 2000-12-31 Total amount of commissions paid to insurance broker USD $771 Dental Insurance Welfare Benefit Yes
HERITAGE VISION PLANS, INC (National Association of Insurance Commissioners NAIC id number: 11204 )
Policy contract number	4010-00
Policy instance	1
Insurance contract or identification number 4010-00 Number of Individuals Covered 207 Insurance policy start date 2000-11-01 Insurance policy end date 2001-05-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,153