401k Plan data: GAMETIME WELFARE BENEFIT SEC. 125 PLAN plan

GAMETIME WELFARE BENEFIT SEC. 125 PLAN 401k Plan overview

Plan Name	GAMETIME WELFARE BENEFIT SEC. 125 PLAN
Plan identification number	503

GAMETIME WELFARE BENEFIT SEC. 125 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

GAMETIME, A DIVISION OF PLAYCORE WISCONSIN, INC. has sponsored the creation of one or more 401k plans.

Company Name: GAMETIME, A DIVISION OF PLAYCORE WISCONSIN, INC.

Employer identification number (EIN): 391720480

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GAMETIME WELFARE BENEFIT SEC. 125 PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-07-01 MICHAEL LOVE 2024-01-26
503 2021-07-01 MICHAEL LOVE 2023-03-15
503 2020-07-01 MICHAEL LOVE 2022-02-16
503 2019-07-01 MICHAEL LOVE 2021-03-16
503 2018-07-01 MICHAEL LOVE 2020-01-16
503 2017-07-01
503 2016-07-01
503 2015-07-01
503 2014-07-01
503 2013-07-01
503 2012-07-01 S. SPENCER CHEAK
503 2011-07-01 S. SPENCER CHEAK
503 2009-07-01 S. SPENCER CHEAK

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
503	2022-07-01	MICHAEL LOVE	2024-01-26
503	2021-07-01	MICHAEL LOVE	2023-03-15
503	2020-07-01	MICHAEL LOVE	2022-02-16
503	2019-07-01	MICHAEL LOVE	2021-03-16
503	2018-07-01	MICHAEL LOVE	2020-01-16
503	2017-07-01
503	2016-07-01
503	2015-07-01
503	2014-07-01
503	2013-07-01
503	2012-07-01	S. SPENCER CHEAK
503	2011-07-01	S. SPENCER CHEAK
503	2009-07-01	S. SPENCER CHEAK

Plan Statistics for GAMETIME WELFARE BENEFIT SEC. 125 PLAN

401k plan membership statisitcs for GAMETIME WELFARE BENEFIT SEC. 125 PLAN

Measure Date Value
2022: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 1,523
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 2,250
Total of all active and inactive participants 2022-07-01 2,250
2021: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 1,600
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 1,523
Total of all active and inactive participants 2021-07-01 1,523
2020: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 1,999
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 1,600
Total of all active and inactive participants 2020-07-01 1,600
2019: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 1,999
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 1,999
Total of all active and inactive participants 2019-07-01 1,999
2018: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 931
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 1,999
Total of all active and inactive participants 2018-07-01 1,999
2017: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 1,081
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 931
Total of all active and inactive participants 2017-07-01 931
2016: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 1,280
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 1,081
Total of all active and inactive participants 2016-07-01 1,081
2015: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 1,280
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 1,280
Total of all active and inactive participants 2015-07-01 1,280
2014: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 754
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 1,280
Total of all active and inactive participants 2014-07-01 1,280
2013: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 763
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 754
Total of all active and inactive participants 2013-07-01 754
2012: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 498
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 763
Total of all active and inactive participants 2012-07-01 763
2011: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 468
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 498
Total of all active and inactive participants 2011-07-01 498
2009: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 393
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 432
Total of all active and inactive participants 2009-07-01 432

Measure	Date	Value
2022: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	1,523
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	2,250
Total of all active and inactive participants	2022-07-01	2,250
2021: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	1,600
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	1,523
Total of all active and inactive participants	2021-07-01	1,523
2020: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	1,999
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	1,600
Total of all active and inactive participants	2020-07-01	1,600
2019: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	1,999
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	1,999
Total of all active and inactive participants	2019-07-01	1,999
2018: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	931
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	1,999
Total of all active and inactive participants	2018-07-01	1,999
2017: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	1,081
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	931
Total of all active and inactive participants	2017-07-01	931
2016: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	1,280
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	1,081
Total of all active and inactive participants	2016-07-01	1,081
2015: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	1,280
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	1,280
Total of all active and inactive participants	2015-07-01	1,280
2014: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	754
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	1,280
Total of all active and inactive participants	2014-07-01	1,280
2013: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	763
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	754
Total of all active and inactive participants	2013-07-01	754
2012: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	498
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	763
Total of all active and inactive participants	2012-07-01	763
2011: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	468
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	498
Total of all active and inactive participants	2011-07-01	498
2009: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	393
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	432
Total of all active and inactive participants	2009-07-01	432

Form 5500 Responses for GAMETIME WELFARE BENEFIT SEC. 125 PLAN

2022: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: GAMETIME WELFARE BENEFIT SEC. 125 PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	This submission is the final filing	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI 960518

Policy instance

Insurance contract or identification number	AI 960518
Number of Individuals Covered	566
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,854
Total amount of fees paid to insurance company	USD $3,215
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $117,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,854
Amount paid for insurance broker fees	962
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	475
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $61,375
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $262,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,375
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 960516

Policy instance

Insurance contract or identification number	CI 960516
Number of Individuals Covered	541
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,694
Total amount of fees paid to insurance company	USD $2,901
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $108,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,694
Amount paid for insurance broker fees	892
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD068212

Policy instance

Insurance contract or identification number	NYD068212
Number of Individuals Covered	23
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

HC 960137

Policy instance

Insurance contract or identification number	HC 960137
Number of Individuals Covered	359
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $11,407
Total amount of fees paid to insurance company	USD $2,312
Other welfare benefits provided	HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $81,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,407
Amount paid for insurance broker fees	791
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

7113

Policy instance

Insurance contract or identification number	7113
Number of Individuals Covered	3249
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $58,597
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 $58,597
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	2250
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,880
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $96,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,880
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

V7113

Policy instance

Insurance contract or identification number	V7113
Number of Individuals Covered	2628
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $13,923
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,923
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $24,107
Total amount of fees paid to insurance company	USD $3,484
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $134,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,107
Amount paid for insurance broker fees	3484
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,369
Total amount of fees paid to insurance company	USD $2,931
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,369
Amount paid for insurance broker fees	2931
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $17,835
Total amount of fees paid to insurance company	USD $2,369
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,835
Amount paid for insurance broker fees	2369
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 960516

Policy instance

Insurance contract or identification number	CI 960516
Number of Individuals Covered	465
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,546
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $147,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,107
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI 960518

Policy instance

Insurance contract or identification number	AI 960518
Number of Individuals Covered	422
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $16,377
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $107,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,829
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

HC 960137

Policy instance

Insurance contract or identification number	HC 960137
Number of Individuals Covered	551
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,789
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $128,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,490
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

7113

Policy instance

Insurance contract or identification number	7113
Number of Individuals Covered	2868
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $49,940
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 $37,435
Insurance broker organization code?	3

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	1010
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,887
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $206,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,363
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	1523
Insurance policy start date	2021-04-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,073
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,073
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	1523
Insurance policy start date	2021-04-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,399
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $32,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,399
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	1523
Insurance policy start date	2021-04-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $30,337
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $283,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,337
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	1523
Insurance policy start date	2021-04-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,823
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $221,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,823
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,629
Total amount of fees paid to insurance company	USD $436
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $15,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,629
Amount paid for insurance broker fees	436
Insurance broker organization code?	3

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	937
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $26,654
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,402
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	1600
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,903
Total amount of fees paid to insurance company	USD $3,238
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $407,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,903
Amount paid for insurance broker fees	3238
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	1189
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,903
Total amount of fees paid to insurance company	USD $3,238
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $338,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,903
Amount paid for insurance broker fees	3238
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	513
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $54,708
Total amount of fees paid to insurance company	USD $2,967
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $273,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,708
Amount paid for insurance broker fees	2967
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 960516

Policy instance

Insurance contract or identification number	CI 960516
Number of Individuals Covered	398
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $24,182
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $120,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,182
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI 960518

Policy instance

Insurance contract or identification number	AI 960518
Number of Individuals Covered	362
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,454
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $82,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,454
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

HC 960137

Policy instance

Insurance contract or identification number	HC 960137
Number of Individuals Covered	450
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,025
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $106,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,025
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

7113

Policy instance

Insurance contract or identification number	7113
Number of Individuals Covered	2722
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $49,638
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 $49,638
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	1600
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $8,425
Total amount of fees paid to insurance company	USD $473
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $49,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,425
Amount paid for insurance broker fees	473
Insurance broker organization code?	3

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	962
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $26,366
Total amount of fees paid to insurance company	USD $7,587
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,963
Insurance broker organization code?	3
Amount paid for insurance broker fees	7587

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	1999
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $76,226
Total amount of fees paid to insurance company	USD $4,049
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $500,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,226
Amount paid for insurance broker fees	4049
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	2012
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $22,009
Total amount of fees paid to insurance company	USD $3,177
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $362,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,009
Amount paid for insurance broker fees	3177
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	633
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $63,211
Total amount of fees paid to insurance company	USD $2,127
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $319,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,211
Amount paid for insurance broker fees	2127
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 960516

Policy instance

Insurance contract or identification number	CI 960516
Number of Individuals Covered	384
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $26,684
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $125,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,684
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

HC 960137

Policy instance

Insurance contract or identification number	HC 960137
Number of Individuals Covered	341
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,487
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $104,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,487
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI 960518

Policy instance

Insurance contract or identification number	AI 960518
Number of Individuals Covered	317
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $17,380
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $81,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,380
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

7113

Policy instance

Insurance contract or identification number	7113
Number of Individuals Covered	2874
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $50,264
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 $50,264
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	317
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $8,942
Total amount of fees paid to insurance company	USD $455
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $52,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,942
Amount paid for insurance broker fees	455
Insurance broker organization code?	3

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )

Policy contract number

7113

Policy instance

Insurance contract or identification number	7113
Number of Individuals Covered	2928
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $43,895
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 $43,895
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

HC 960137

Policy instance

Insurance contract or identification number	HC 960137
Number of Individuals Covered	341
Insurance policy start date	2018-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,591
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $63,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,591
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

AI 960518

Policy instance

Insurance contract or identification number	AI 960518
Number of Individuals Covered	317
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,421
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $57,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,421
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

CI 960516

Policy instance

Insurance contract or identification number	CI 960516
Number of Individuals Covered	384
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,253
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $86,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,253
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	633
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $43,685
Total amount of fees paid to insurance company	USD $3,011
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $256,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,685
Amount paid for insurance broker fees	3011
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	2012
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $59,860
Total amount of fees paid to insurance company	USD $3,601
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $352,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,860
Amount paid for insurance broker fees	3601
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	1999
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $78,707
Total amount of fees paid to insurance company	USD $4,988
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $462,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,707
Amount paid for insurance broker fees	4988
Insurance broker organization code?	3

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	950
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $24,274
Total amount of fees paid to insurance company	USD $11,724
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $189,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,179
Amount paid for insurance broker fees	11724
Insurance broker organization code?	3

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	628
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,738
Total amount of fees paid to insurance company	USD $6,046
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,727
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

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	141
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,947
Total amount of fees paid to insurance company	USD $918
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $59,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	931
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $52,875
Total amount of fees paid to insurance company	USD $3,643
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $311,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYDO68212

Policy instance

Insurance contract or identification number	NYDO68212
Number of Individuals Covered	299
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	109
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $32,429
Total amount of fees paid to insurance company	USD $2,250
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $190,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	932
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $45,939
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $459,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	475
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,171
Total amount of fees paid to insurance company	USD $373
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	362
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $27,186
Total amount of fees paid to insurance company	USD $1,097
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,059
Amount paid for insurance broker fees	1097
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	459
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,455
Total amount of fees paid to insurance company	USD $3,639
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,455
Amount paid for insurance broker fees	3639
Insurance broker organization code?	3
Insurance broker name	WILLIAM R BLAKELY

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	1280
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $42,455
Total amount of fees paid to insurance company	USD $1,627
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $251,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,781
Amount paid for insurance broker fees	1627
Insurance broker organization code?	3
Insurance broker name	CAPITAL STRATEGIES GROUP

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	607
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $29,161
Total amount of fees paid to insurance company	USD $1,110
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,935
Amount paid for insurance broker fees	1110
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	1280
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,399
Total amount of fees paid to insurance company	USD $163
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $25,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,852
Amount paid for insurance broker fees	163
Insurance broker organization code?	3
Insurance broker name	CAPITAL STRATEGIES GROUP

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	124
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,726
Total amount of fees paid to insurance company	USD $1,614
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $50,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $823
Amount paid for insurance broker fees	1371
Insurance broker organization code?	3
Insurance broker name	ADVANCED BENEFIT SYSTEMS

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	535
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $38,643
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $150,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,748
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	754
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $56,396
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,282
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	327
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $38,191
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,344
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	754
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $5,632
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $21,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,020
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	123
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,471
Total amount of fees paid to insurance company	USD $152
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $47,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,114
Insurance broker organization code?	3
Amount paid for insurance broker fees	80
Insurance broker name	ADVANCED BENEFIT SYSTEMS

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	298
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,203
Total amount of fees paid to insurance company	USD $1,979
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,203
Amount paid for insurance broker fees	1979
Insurance broker organization code?	3
Insurance broker name	WILLIAM R BLAKELY

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX965278

Policy instance

Insurance contract or identification number	FLX965278
Number of Individuals Covered	763
Insurance policy start date	2013-03-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $28,350
Total amount of fees paid to insurance company	USD $219
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $166,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,016
Amount paid for insurance broker fees	219
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS2855

Policy instance

Insurance contract or identification number	VS2855
Number of Individuals Covered	158
Insurance policy start date	2012-07-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,721
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,721
Insurance broker organization code?	3
Insurance broker name	BB&T INSURANCE SERVICES INC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT961328

Policy instance

Insurance contract or identification number	VDT961328
Number of Individuals Covered	328
Insurance policy start date	2013-03-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $20,164
Total amount of fees paid to insurance company	USD $138
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,793
Amount paid for insurance broker fees	138
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 966864

Policy instance

Insurance contract or identification number	OK 966864
Number of Individuals Covered	763
Insurance policy start date	2013-03-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $2,941
Total amount of fees paid to insurance company	USD $22
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,595
Amount paid for insurance broker fees	22
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

861784-SHORT

Policy instance

Insurance contract or identification number	861784-SHORT
Number of Individuals Covered	489
Insurance policy start date	2012-08-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $21,268
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $147,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,268
Insurance broker organization code?	3
Insurance broker name	CAPITAL STRATEGIES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	123
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,813
Total amount of fees paid to insurance company	USD $231
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL ILLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,208
Amount paid for insurance broker fees	24
Insurance broker organization code?	3
Insurance broker name	ADVANCED BENEFIT SYSTEMS

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

Policy contract number

VG001997

Policy instance

Insurance contract or identification number	VG001997
Number of Individuals Covered	153
Insurance policy start date	2012-07-01
Insurance policy end date	2013-03-01
Total amount of commissions paid to insurance broker	USD $1,256
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,256
Insurance broker organization code?	3
Insurance broker name	CAPITAL STRATEGIES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK 751336

Policy instance

Insurance contract or identification number	LK 751336
Number of Individuals Covered	494
Insurance policy start date	2013-03-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $20,671
Total amount of fees paid to insurance company	USD $89
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,240
Amount paid for insurance broker fees	89
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SERVICES

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

Policy contract number

00484969

Policy instance

Insurance contract or identification number	00484969
Number of Individuals Covered	272
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,166
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,166
Insurance broker organization code?	3
Insurance broker name	WILLIAM R BLAKELY

LLOYD'S OF LONDON (National Association of Insurance Commissioners NAIC id number: AA-11 )

Policy contract number

13852X12

Policy instance

Insurance contract or identification number	13852X12
Number of Individuals Covered	675
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $16,777
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $167,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,777
Insurance broker organization code?	3
Insurance broker name	CAPITAL STRATEGIES

LLOYD'S OF LONDON (National Association of Insurance Commissioners NAIC id number: AA-11 )

Policy contract number

13852X11

Policy instance

Insurance contract or identification number	13852X11
Number of Individuals Covered	504
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $17,539
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $175,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

861784

Policy instance

Insurance contract or identification number	861784
Number of Individuals Covered	434
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $27,830
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $190,328
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

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	126
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,725
Total amount of fees paid to insurance company	USD $414
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $48,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VG001997

Policy instance

Insurance contract or identification number	VG001997
Number of Individuals Covered	146
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $8,159
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS2855

Policy instance

Insurance contract or identification number	VS2855
Number of Individuals Covered	101
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,960
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,362
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

E7546575

Policy instance

Insurance contract or identification number	E7546575
Number of Individuals Covered	126
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,483
Total amount of fees paid to insurance company	USD $441
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $48,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VG001997

Policy instance

Insurance contract or identification number	VG001997
Number of Individuals Covered	163
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,663
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

UNI-200155

Policy instance

Insurance contract or identification number	UNI-200155
Number of Individuals Covered	468
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $35,821
Total amount of fees paid to insurance company	USD $5,564
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $358,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS2855

Policy instance

Insurance contract or identification number	VS2855
Number of Individuals Covered	80
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,684
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

861784

Policy instance

Insurance contract or identification number	861784
Number of Individuals Covered	449
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $19,554
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $130,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Was this data useful?

If you found the data here useful, PLEASE HELP US. We are a start-up and believe in making information freely available. By linking to us, posting on twitter, facebook and linkedin about us and generally spreading the word, you'll help us to grow. Our vision is to provide high quality data about the activities of all the companies in the world and where possible make it free to use and view. Finding and integrating data from thousands of data sources is time consuming and needs lots of effort. By simply spreading the word about us, you will help us. Please use the share buttons. It will only take a few seconds of your time. Thanks for helping

Information Disclaimer

The information provided on this website is not advice, endorsement or recommendation
The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
You are free to use the information for your own personal research on the understanding to do so is at your own risk.

See full terms and conditions

Company Name:	GAMETIME, A DIVISION OF PLAYCORE WISCONSIN, INC.
Employer identification number (EIN):	391720480
NAIC Classification:	339900