SPS COMPANIES, INC. FLEX PLAN 401k Plan overview

Plan Name	SPS COMPANIES, INC. FLEX PLAN
Plan identification number	502

SPS COMPANIES, INC. FLEX PLAN Benefits

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

401k Sponsoring company profile

SPS COMPANIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:	SPS COMPANIES, INC.
Employer identification number (EIN):	410719467
NAIC Classification:	423700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SPS COMPANIES, INC. FLEX PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01	ECHO HUMMEL		WILLIAM WEBER	2019-07-16
502	2017-01-01	ECHO HUMMEL		BILL WEBER	2018-07-10
502	2016-01-01	ECHO HUMMEL		BILL WEBER	2017-07-17
502	2015-01-01	ECHO HUMMEL		BILL WEBER	2016-09-06
502	2014-01-01	ECHO HUMMEL		BILL WEBER	2015-07-22
502	2013-01-01	ECHO HUMMEL		BILL WEBER	2014-07-15
502	2012-01-01	ECHO HUMMEL		BILL WEBER	2013-07-10
502	2011-01-01	ECHO HUMMEL		BILL WEBER	2012-07-25
502	2009-01-01	WILLIAM J. WEBER		WILLIAM J. WEBER	2010-08-17

Plan Statistics for SPS COMPANIES, INC. FLEX PLAN

401k plan membership statisitcs for SPS COMPANIES, INC. FLEX PLAN

Measure	Date	Value
2022: SPS COMPANIES, INC. FLEX PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	139
Number of retired or separated participants receiving benefits	2022-01-01	4
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	143
2021: SPS COMPANIES, INC. FLEX PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	130
Number of retired or separated participants receiving benefits	2021-01-01	4
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	134
2020: SPS COMPANIES, INC. FLEX PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	141
Number of retired or separated participants receiving benefits	2020-01-01	5
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	146
2019: SPS COMPANIES, INC. FLEX PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	150
Number of retired or separated participants receiving benefits	2019-01-01	3
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	153
2018: SPS COMPANIES, INC. FLEX PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	156
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	156
2017: SPS COMPANIES, INC. FLEX PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	138
Number of retired or separated participants receiving benefits	2017-01-01	1
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	139
2016: SPS COMPANIES, INC. FLEX PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	147
Number of retired or separated participants receiving benefits	2016-01-01	2
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	149
2015: SPS COMPANIES, INC. FLEX PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	142
Number of retired or separated participants receiving benefits	2015-01-01	5
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	147
2014: SPS COMPANIES, INC. FLEX PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	135
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	136
2013: SPS COMPANIES, INC. FLEX PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	113
Number of retired or separated participants receiving benefits	2013-01-01	1
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	114
2012: SPS COMPANIES, INC. FLEX PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	118
Number of retired or separated participants receiving benefits	2012-01-01	3
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	121
2011: SPS COMPANIES, INC. FLEX PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	112
Number of retired or separated participants receiving benefits	2011-01-01	1
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	113
2009: SPS COMPANIES, INC. FLEX PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	120
Number of retired or separated participants receiving benefits	2009-01-01	17
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	137

Form 5500 Responses for SPS COMPANIES, INC. FLEX PLAN

2022: SPS COMPANIES, INC. FLEX PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SPS COMPANIES, INC. FLEX PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: SPS COMPANIES, INC. FLEX 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: SPS COMPANIES, INC. FLEX 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: SPS COMPANIES, INC. FLEX 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: SPS COMPANIES, INC. FLEX 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: SPS COMPANIES, INC. FLEX PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: SPS COMPANIES, INC. FLEX PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: SPS COMPANIES, INC. FLEX PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: SPS COMPANIES, INC. FLEX PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: SPS COMPANIES, INC. FLEX PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: SPS COMPANIES, INC. FLEX PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: SPS COMPANIES, INC. FLEX PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $255 Total amount of fees paid to insurance company USD $56 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,218 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $255 Amount paid for insurance broker fees 56 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 52 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $18,516 Total amount of fees paid to insurance company USD $1,581 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $671,243 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,683 Amount paid for insurance broker fees 1581 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 21 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $6,018 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $120,911 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,018 Insurance broker organization code? 3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	1089991
Policy instance	9
Insurance contract or identification number 1089991 Number of Individuals Covered 23 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,185 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,185 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $225 Total amount of fees paid to insurance company USD $57 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,246 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $225 Amount paid for insurance broker fees 57 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,651 Total amount of fees paid to insurance company USD $456 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,253 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,651 Amount paid for insurance broker fees 456 Additional information about fees paid to insurance broker OVERRIDE FEEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,822 Total amount of fees paid to insurance company USD $499 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,822 Amount paid for insurance broker fees 499 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $34 Total amount of fees paid to insurance company USD $9 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $374 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34 Amount paid for insurance broker fees 9 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 143 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,594 Total amount of fees paid to insurance company USD $860 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,594 Amount paid for insurance broker fees 860 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 57 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $20,803 Total amount of fees paid to insurance company USD $2,349 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $643,003 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,803 Amount paid for insurance broker fees 2349 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 26 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $6,131 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $126,543 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,131 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $264 Total amount of fees paid to insurance company USD $52 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,093 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $264 Amount paid for insurance broker fees 52 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $212 Total amount of fees paid to insurance company USD $52 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,119 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $212 Amount paid for insurance broker fees 52 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,521 Total amount of fees paid to insurance company USD $701 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,805 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,521 Amount paid for insurance broker fees 701 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $38 Total amount of fees paid to insurance company USD $8 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $376 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38 Amount paid for insurance broker fees 8 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,001 Total amount of fees paid to insurance company USD $701 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $32,008 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,001 Amount paid for insurance broker fees 701 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	1089991
Policy instance	9
Insurance contract or identification number 1089991 Number of Individuals Covered 26 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,234 Total amount of fees paid to insurance company USD $195 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,218 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,234 Insurance broker organization code? 3 Amount paid for insurance broker fees 195 Additional information about fees paid to insurance broker BONUS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 134 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,867 Total amount of fees paid to insurance company USD $440 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,667 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,867 Amount paid for insurance broker fees 440 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 60 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $22,600 Total amount of fees paid to insurance company USD $2,464 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $737,544 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,600 Amount paid for insurance broker fees 2464 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 28 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,572 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $148,622 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,572 Insurance broker organization code? 3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	1089991
Policy instance	9
Insurance contract or identification number 1089991 Number of Individuals Covered 32 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,760 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,429 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $214 Total amount of fees paid to insurance company USD $23 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,114 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $214 Amount paid for insurance broker fees 23 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,455 Total amount of fees paid to insurance company USD $180 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,455 Amount paid for insurance broker fees 180 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,785 Total amount of fees paid to insurance company USD $188 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,851 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,785 Amount paid for insurance broker fees 188 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $30 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $296 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,499 Total amount of fees paid to insurance company USD $311 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,993 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,499 Amount paid for insurance broker fees 311 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	04U8223
Policy instance	10
Insurance contract or identification number 04U8223 Number of Individuals Covered 42 Insurance policy start date 2020-01-01 Insurance policy end date 2020-02-28 Total amount of commissions paid to insurance broker USD $1,680 Total amount of fees paid to insurance company USD $320 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $48,220 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,680 Insurance broker organization code? 3 Amount paid for insurance broker fees 320 Additional information about fees paid to insurance broker BONUS
ALL SAVERS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82406 )
Policy contract number	5400 20766
Policy instance	11
Insurance contract or identification number 5400 20766 Number of Individuals Covered 29 Insurance policy start date 2020-03-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $10,080 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $224,764 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,080 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 146 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $265 Total amount of fees paid to insurance company USD $22 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,116 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $265 Amount paid for insurance broker fees 22 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $237 Total amount of fees paid to insurance company USD $17 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,374 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $237 Amount paid for insurance broker fees 17 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $278 Total amount of fees paid to insurance company USD $17 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,227 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $278 Amount paid for insurance broker fees 17 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 29 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $6,829 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $161,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,829 Insurance broker organization code? 3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 66 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $23,961 Total amount of fees paid to insurance company USD $3,528 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $796,132 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,961 Amount paid for insurance broker fees 3528 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,724 Total amount of fees paid to insurance company USD $132 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,160 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,724 Amount paid for insurance broker fees 132 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,862 Total amount of fees paid to insurance company USD $126 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,862 Amount paid for insurance broker fees 126 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	04U8223
Policy instance	10
Insurance contract or identification number 04U8223 Number of Individuals Covered 40 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $9,720 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $244,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,720 Insurance broker organization code? 3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	1089991
Policy instance	9
Insurance contract or identification number 1089991 Number of Individuals Covered 31 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,070 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,804 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,403 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,929 Total amount of fees paid to insurance company USD $228 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,431 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,929 Amount paid for insurance broker fees 228 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 153 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $40 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $401 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 73 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $23,440 Total amount of fees paid to insurance company USD $2,734 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $773,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,440 Amount paid for insurance broker fees 2734 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 40 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $7,175 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $178,753 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,175 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $256 Total amount of fees paid to insurance company USD $29 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,050 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $256 Amount paid for insurance broker fees 29 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,485 Total amount of fees paid to insurance company USD $194 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,062 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,485 Amount paid for insurance broker fees 194 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,347 Total amount of fees paid to insurance company USD $205 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,649 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,347 Amount paid for insurance broker fees 205 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,485 Total amount of fees paid to insurance company USD $194 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,851 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,485 Amount paid for insurance broker fees 194 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $35 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $349 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,415 Total amount of fees paid to insurance company USD $324 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,322 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,415 Amount paid for insurance broker fees 324 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H41966
Policy instance	9
Insurance contract or identification number H41966 Number of Individuals Covered 18 Insurance policy start date 2018-01-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $211 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,851 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $146 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	4U8223
Policy instance	10
Insurance contract or identification number 4U8223 Number of Individuals Covered 40 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $8,970 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $242,272 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,970 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	679634
Policy instance	10
Insurance contract or identification number 679634 Number of Individuals Covered 37 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $5,760 Total amount of fees paid to insurance company USD $644 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $133,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,760 Insurance broker organization code? 3 Amount paid for insurance broker fees 644 Additional information about fees paid to insurance broker BONUS Insurance broker name GALLAGHER BENEFIT SERVICES INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H41966
Policy instance	9
Insurance contract or identification number H41966 Number of Individuals Covered 16 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,250 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,824 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $881 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,260 Total amount of fees paid to insurance company USD $1,146 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $26,079 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,260 Amount paid for insurance broker fees 1146 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $36 Total amount of fees paid to insurance company USD $8 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $358 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36 Amount paid for insurance broker fees 8 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 77 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $23,292 Total amount of fees paid to insurance company USD $3,920 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $786,579 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,292 Amount paid for insurance broker fees 3920 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 38 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $161,425 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	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $290 Total amount of fees paid to insurance company USD $96 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,322 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $290 Amount paid for insurance broker fees 96 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $211 Total amount of fees paid to insurance company USD $45 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,114 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $211 Amount paid for insurance broker fees 45 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,459 Total amount of fees paid to insurance company USD $441 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,392 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,459 Amount paid for insurance broker fees 441 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 138 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,553 Total amount of fees paid to insurance company USD $455 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,531 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,553 Amount paid for insurance broker fees 455 Additional information about fees paid to insurance broker OVERRIDE FEES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H41966
Policy instance	9
Insurance contract or identification number H41966 Number of Individuals Covered 38 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,441 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $695 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,724 Total amount of fees paid to insurance company USD $288 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No 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 $29,794 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,724 Amount paid for insurance broker fees 288 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $32 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $317 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,340 Total amount of fees paid to insurance company USD $131 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,400 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,340 Amount paid for insurance broker fees 131 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,110 Total amount of fees paid to insurance company USD $136 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,064 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,110 Amount paid for insurance broker fees 136 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $188 Total amount of fees paid to insurance company USD $19 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,877 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $188 Amount paid for insurance broker fees 19 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 49 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $8,977 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $177,275 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,977 Insurance broker organization code? 3 Insurance broker name MISSOURI VALLEY INSURANCE INC.
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 168 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $22,237 Total amount of fees paid to insurance company USD $511 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $678,472 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,237 Amount paid for insurance broker fees 511 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $310 Total amount of fees paid to insurance company USD $27 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $310 Amount paid for insurance broker fees 27 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	679634
Policy instance	10
Insurance contract or identification number 679634 Number of Individuals Covered 37 Insurance policy start date 2015-03-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $794 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $162,251 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 794 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	3
Insurance contract or identification number SOK602293 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $336 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,690 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $336 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	5
Insurance contract or identification number SGD603535 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,030 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit 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 $13,531 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,030 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	6
Insurance contract or identification number VDT600781 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $1,305 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,305 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	7
Insurance contract or identification number SOK602377 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $31 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $315 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	8
Insurance contract or identification number SGM603587 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,602 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,813 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,602 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H41966
Policy instance	9
Insurance contract or identification number H41966 Number of Individuals Covered 15 Insurance policy start date 2014-10-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $329 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,610 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $232 Insurance broker organization code? 3 Insurance broker name ROGERS BENEFIT GROUP INC
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	2
Insurance contract or identification number HP040157 Number of Individuals Covered 37 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $8,185 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $190,922 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,185 Insurance broker organization code? 3 Insurance broker name MISSOURI VALLEY INSURANCE INC.
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	1
Insurance contract or identification number 146995 Number of Individuals Covered 75 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $20,856 Total amount of fees paid to insurance company USD $518 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $757,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,856 Amount paid for insurance broker fees 518 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	4
Insurance contract or identification number SGM603705 Number of Individuals Covered 135 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $186 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,859 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $186 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602377
Policy instance	8
Insurance contract or identification number SOK602377 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $29 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH 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 $285 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGD603535
Policy instance	6
Insurance contract or identification number SGD603535 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,861 Total amount of fees paid to insurance company USD $290 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit 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 $12,408 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,861 Amount paid for insurance broker fees 290 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603705
Policy instance	5
Insurance contract or identification number SGM603705 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $169 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,689 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $169 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK602293
Policy instance	4
Insurance contract or identification number SOK602293 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $332 Total amount of fees paid to insurance company USD $64 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,654 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $332 Amount paid for insurance broker fees 64 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )
Policy contract number	HP040157
Policy instance	3
Insurance contract or identification number HP040157 Number of Individuals Covered 21 Insurance policy start date 2013-12-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,457 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,567 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,457 Insurance broker organization code? 3 Insurance broker name MISSOURI VALLEY INSURANCE INC.
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	2
Insurance contract or identification number 146995 Number of Individuals Covered 173 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $19,244 Total amount of fees paid to insurance company USD $588 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $641,465 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,244 Amount paid for insurance broker fees 588 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number	75644
Policy instance	1
Insurance contract or identification number 75644 Number of Individuals Covered 46 Insurance policy start date 2013-01-01 Insurance policy end date 2013-11-30 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM603587
Policy instance	9
Insurance contract or identification number SGM603587 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,479 Total amount of fees paid to insurance company USD $658 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,830 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,479 Amount paid for insurance broker fees 658 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT600781
Policy instance	7
Insurance contract or identification number VDT600781 Number of Individuals Covered 113 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,244 Total amount of fees paid to insurance company USD $343 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,443 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,244 Amount paid for insurance broker fees 343 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122368
Policy instance	6
Insurance contract or identification number 10122368 Number of Individuals Covered 109 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $2,337 Total amount of fees paid to insurance company USD $504 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit 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 $15,580 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,337 Insurance broker organization code? 3 Amount paid for insurance broker fees 504 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker name GALLAGHER BENEFIT SERVICES INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400122370
Policy instance	5
Insurance contract or identification number 400122370 Number of Individuals Covered 65 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,480 Total amount of fees paid to insurance company USD $489 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided WEEKLY INCOME Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,480 Insurance broker organization code? 3 Amount paid for insurance broker fees 489 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker name GALLAGHER BENEFIT SERVICES INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400122369
Policy instance	4
Insurance contract or identification number 400122369 Number of Individuals Covered 67 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,964 Total amount of fees paid to insurance company USD $1,070 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,711 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,964 Insurance broker organization code? 3 Amount paid for insurance broker fees 1070 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker name GALLAGHER BENEFIT SERVICES INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122367
Policy instance	3
Insurance contract or identification number 10122367 Number of Individuals Covered 118 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $222 Total amount of fees paid to insurance company USD $75 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,221 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $222 Insurance broker organization code? 3 Amount paid for insurance broker fees 75 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker name GALLAGHER BENEFIT SERVICES INC
MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )
Policy contract number	146995
Policy instance	2
Insurance contract or identification number 146995 Number of Individuals Covered 107 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $20,030 Total amount of fees paid to insurance company USD $532 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $436,338 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,030 Amount paid for insurance broker fees 532 Additional information about fees paid to insurance broker BROKER INCENTIVE PROGRAM Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number	75644
Policy instance	1
Insurance contract or identification number 75644 Number of Individuals Covered 45 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number	CN905
Policy instance	2
Insurance contract or identification number CN905 Number of Individuals Covered 78 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $10,089 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $580,108 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122368
Policy instance	6
Insurance contract or identification number 10122368 Number of Individuals Covered 104 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $2,218 Total amount of fees paid to insurance company USD $563 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,784 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number	75644
Policy instance	1
Insurance contract or identification number 75644 Number of Individuals Covered 37 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122367
Policy instance	3
Insurance contract or identification number 10122367 Number of Individuals Covered 113 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $221 Total amount of fees paid to insurance company USD $88 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,214 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400122369
Policy instance	4
Insurance contract or identification number 400122369 Number of Individuals Covered 71 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,924 Total amount of fees paid to insurance company USD $1,642 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & 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 $31,393 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400122370
Policy instance	5
Insurance contract or identification number 400122370 Number of Individuals Covered 64 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,434 Total amount of fees paid to insurance company USD $508 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided WEEKLY INCOME Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,343 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number	CN905
Policy instance	2
Insurance contract or identification number CN905 Number of Individuals Covered 84 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $13,091 Total amount of fees paid to insurance company USD $50 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $621,760 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,091 Amount paid for insurance broker fees 50 Additional information about fees paid to insurance broker AGENT/BROKER INCENTIVES Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	1D018868
Policy instance	3
Insurance contract or identification number 1D018868 Number of Individuals Covered 107 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $9,441 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $94,410 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,441 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SVCS INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122367
Policy instance	4
Insurance contract or identification number 10122367 Number of Individuals Covered 125 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $251 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,508 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $251 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SVCS INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10122368
Policy instance	5
Insurance contract or identification number 10122368 Number of Individuals Covered 108 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,414 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit 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 $16,096 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 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SVCS INC
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number	75644
Policy instance	1
Insurance contract or identification number 75644 Number of Individuals Covered 38 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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