401k Plan data: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST plan

HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 401k Plan overview

Plan Name	HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST
Plan identification number	501

HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST Benefits

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

401k Sponsoring company profile

HARTIG DRUG COMPANY has sponsored the creation of one or more 401k plans.

Company Name: HARTIG DRUG COMPANY

Employer identification number (EIN): 420298860

NAIC Classification: 446110
NAIC Description: Pharmacies and Drug Stores

Additional information about HARTIG DRUG COMPANY

Jurisdiction of Incorporation: Iowa Secretary of State Business Entities

Incorporation Date: 1917-02-24

Company Identification Number: 017939

Legal Registered Office Address: 703 MAIN ST

DUBUQUE
United States of America (USA)
52001

More information about HARTIG DRUG COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01 CARRIE TEMPERLY 2022-06-13
501 2021-01-01
501 2020-01-01 CHARLIE HARTIG 2021-10-11
501 2019-01-01 DICK HARTIG 2020-05-21
501 2018-01-01 DICK HARTIG 2019-09-24
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 MARILYN KAMMILLER
501 2011-01-01 MARILYN KAMMILLER

Plan Statistics for HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST

401k plan membership statisitcs for HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST

Measure Date Value
2022: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2022 401k membership
Total participants, beginning-of-year 2022-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 131
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 131
2021: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2021 401k membership
Total participants, beginning-of-year 2021-01-01 187
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 177
Number of retired or separated participants receiving benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 177
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
2020: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2020 401k membership
Total participants, beginning-of-year 2020-01-01 194
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 187
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 188
2019: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2019 401k membership
Total participants, beginning-of-year 2019-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 251
Number of retired or separated participants receiving benefits 2019-01-01 4
Total of all active and inactive participants 2019-01-01 255
2018: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2018 401k membership
Total participants, beginning-of-year 2018-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 209
Number of retired or separated participants receiving benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 212
2017: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2017 401k membership
Total participants, beginning-of-year 2017-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 245
Number of retired or separated participants receiving benefits 2017-01-01 2
Total of all active and inactive participants 2017-01-01 247
2016: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2016 401k membership
Total participants, beginning-of-year 2016-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 255
Number of retired or separated participants receiving benefits 2016-01-01 2
Total of all active and inactive participants 2016-01-01 257
2015: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2015 401k membership
Total participants, beginning-of-year 2015-01-01 161
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 166
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 166
2014: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2014 401k membership
Total participants, beginning-of-year 2014-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 160
Number of retired or separated participants receiving benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 161
2013: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2013 401k membership
Total participants, beginning-of-year 2013-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 153
Total of all active and inactive participants 2013-01-01 153
2012: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2012 401k membership
Total participants, beginning-of-year 2012-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 100
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 101
2011: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2011 401k membership
Total participants, beginning-of-year 2011-01-01 90
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 106
Total of all active and inactive participants 2011-01-01 106

Measure	Date	Value
2022: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2022 401k membership
Total participants, beginning-of-year	2022-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	131
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	131
2021: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2021 401k membership
Total participants, beginning-of-year	2021-01-01	187
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	177
Number of retired or separated participants receiving benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	177
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
2020: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2020 401k membership
Total participants, beginning-of-year	2020-01-01	194
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	187
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	188
2019: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2019 401k membership
Total participants, beginning-of-year	2019-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	251
Number of retired or separated participants receiving benefits	2019-01-01	4
Total of all active and inactive participants	2019-01-01	255
2018: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2018 401k membership
Total participants, beginning-of-year	2018-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	209
Number of retired or separated participants receiving benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	212
2017: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2017 401k membership
Total participants, beginning-of-year	2017-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	245
Number of retired or separated participants receiving benefits	2017-01-01	2
Total of all active and inactive participants	2017-01-01	247
2016: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2016 401k membership
Total participants, beginning-of-year	2016-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	255
Number of retired or separated participants receiving benefits	2016-01-01	2
Total of all active and inactive participants	2016-01-01	257
2015: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2015 401k membership
Total participants, beginning-of-year	2015-01-01	161
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	166
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	166
2014: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2014 401k membership
Total participants, beginning-of-year	2014-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	160
Number of retired or separated participants receiving benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	161
2013: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2013 401k membership
Total participants, beginning-of-year	2013-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	153
Total of all active and inactive participants	2013-01-01	153
2012: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2012 401k membership
Total participants, beginning-of-year	2012-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	100
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	101
2011: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2011 401k membership
Total participants, beginning-of-year	2011-01-01	90
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	106
Total of all active and inactive participants	2011-01-01	106

Financial Data on HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST

Measure	Date	Value
2013 : HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2013 401k financial data
Total income from all sources	2013-12-31	$789,381
Expenses. Total of all expenses incurred	2013-12-31	$791,707
Benefits paid (including direct rollovers)	2013-12-31	$787,063
Total plan assets at end of year	2013-12-31	$12,708
Total plan assets at beginning of year	2013-12-31	$15,034
Total contributions received or receivable from participants	2013-12-31	$373,428
Contributions received from other sources (not participants or employers)	2013-12-31	$6,213
Other income received	2013-12-31	$18
Net income (gross income less expenses)	2013-12-31	$-2,326
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$12,708
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$15,034
Total contributions received or receivable from employer(s)	2013-12-31	$409,722
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$4,644
2012 : HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2012 401k financial data
Total income from all sources	2012-12-31	$749,659
Expenses. Total of all expenses incurred	2012-12-31	$745,545
Benefits paid (including direct rollovers)	2012-12-31	$741,217
Total plan assets at end of year	2012-12-31	$15,034
Total plan assets at beginning of year	2012-12-31	$10,920
Total contributions received or receivable from participants	2012-12-31	$356,624
Contributions received from other sources (not participants or employers)	2012-12-31	$10,865
Other income received	2012-12-31	$19
Net income (gross income less expenses)	2012-12-31	$4,114
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$15,034
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$10,920
Total contributions received or receivable from employer(s)	2012-12-31	$382,151
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$4,328
2011 : HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2011 401k financial data
Total income from all sources	2011-12-31	$162,318
Expenses. Total of all expenses incurred	2011-12-31	$154,572
Benefits paid (including direct rollovers)	2011-12-31	$150,517
Total plan assets at end of year	2011-12-31	$10,920
Total plan assets at beginning of year	2011-12-31	$3,174
Total contributions received or receivable from participants	2011-12-31	$47,538
Other income received	2011-12-31	$4
Net income (gross income less expenses)	2011-12-31	$7,746
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$10,920
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$3,174
Total contributions received or receivable from employer(s)	2011-12-31	$114,776
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$4,055

Form 5500 Responses for HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST

2022: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan 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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: HARTIG DRUG COMPANY EMPLOYEE BENEFITS TRUST 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	80
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,495
Total amount of fees paid to insurance company	USD $7,275
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL. LONG-TERM DISABILITY, VOL. SHORT-TERM DISABILITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $63,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,453
Insurance broker organization code?	3
Amount paid for insurance broker fees	6302
Additional information about fees paid to insurance broker	OTHER FEES

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0226625

Policy instance

Insurance contract or identification number	0226625
Number of Individuals Covered	73
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,920
Total amount of fees paid to insurance company	USD $1,340
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	ACCIDENT, CRITICAL ILLNESS, CANCER
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 $16,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,295
Amount paid for insurance broker fees	327
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

14972

Policy instance

Insurance contract or identification number	14972
Number of Individuals Covered	236
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,398
Total amount of fees paid to insurance company	USD $4,420
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	Yes
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, VOL. LIFE AND 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 $110,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,190
Insurance broker organization code?	3
Amount paid for insurance broker fees	4420
Additional information about fees paid to insurance broker	FEES PAID

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

2004317

Policy instance

Insurance contract or identification number	2004317
Number of Individuals Covered	206
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,334
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ORGAN TRANSPLANT
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 $13,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,334
Insurance broker organization code?	3

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

Policy contract number

GL 155981

Policy instance

Insurance contract or identification number	GL 155981
Number of Individuals Covered	49
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,181
Total amount of fees paid to insurance company	USD $2,428
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,379
Insurance broker organization code?	3
Amount paid for insurance broker fees	2253
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

VPS 327101

Policy instance

Insurance contract or identification number	VPS 327101
Number of Individuals Covered	25
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,585
Total amount of fees paid to insurance company	USD $2,872
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,326
Insurance broker organization code?	3
Amount paid for insurance broker fees	2823
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

VPL 302142

Policy instance

Insurance contract or identification number	VPL 302142
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,356
Total amount of fees paid to insurance company	USD $3,653
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,520
Insurance broker organization code?	3
Amount paid for insurance broker fees	3545
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	242
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,278
Total amount of fees paid to insurance company	USD $990
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,486
Insurance broker organization code?	3
Amount paid for insurance broker fees	990
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

VAR 207014

Policy instance

Insurance contract or identification number	VAR 207014
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $880
Total amount of fees paid to insurance company	USD $400
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $574
Insurance broker organization code?	3
Amount paid for insurance broker fees	383
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

G 164899

Policy instance

Insurance contract or identification number	G 164899
Number of Individuals Covered	91
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,736
Total amount of fees paid to insurance company	USD $3,585
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,045
Insurance broker organization code?	3
Amount paid for insurance broker fees	3364
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5966325

Policy instance

Insurance contract or identification number	5966325
Number of Individuals Covered	218
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,892
Total amount of fees paid to insurance company	USD $8,354
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,367
Amount paid for insurance broker fees	2713
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

2004317

Policy instance

Insurance contract or identification number	2004317
Number of Individuals Covered	225
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,388
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ORGAN TRANSPLANT
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 $13,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,388
Insurance broker organization code?	3

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	242
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $44,375
Total amount of fees paid to insurance company	USD $570
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $133,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,331
Insurance broker organization code?	3
Amount paid for insurance broker fees	157
Additional information about fees paid to insurance broker	OTHER FEES

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5966325

Policy instance

Insurance contract or identification number	5966325
Number of Individuals Covered	218
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,892
Total amount of fees paid to insurance company	USD $8,354
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $91,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,367
Amount paid for insurance broker fees	2713
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

2004317

Policy instance

Insurance contract or identification number	2004317
Number of Individuals Covered	225
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,388
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $13,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,388
Insurance broker organization code?	3

PREFERRED HEALTH CHOICES LLC (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

990076

Policy instance

Insurance contract or identification number	990076
Number of Individuals Covered	249
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	139
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9475618

Policy instance

Insurance contract or identification number	9475618
Number of Individuals Covered	139
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $21,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VAR 207014

Policy instance

Insurance contract or identification number	VAR 207014
Number of Individuals Covered	31
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $276
Total amount of fees paid to insurance company	USD $333
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

GL 155981

Policy instance

Insurance contract or identification number	GL 155981
Number of Individuals Covered	54
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,488
Total amount of fees paid to insurance company	USD $2,343
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,787
Amount paid for insurance broker fees	1215
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	238
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $172
Total amount of fees paid to insurance company	USD $562
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $172
Amount paid for insurance broker fees	470
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VPL 302142

Policy instance

Insurance contract or identification number	VPL 302142
Number of Individuals Covered	17
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $717
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Amount paid for insurance broker fees	609
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VPS 327101

Policy instance

Insurance contract or identification number	VPS 327101
Number of Individuals Covered	26
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $185
Total amount of fees paid to insurance company	USD $671
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $185
Amount paid for insurance broker fees	572
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

G 164899

Policy instance

Insurance contract or identification number	G 164899
Number of Individuals Covered	81
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,068
Total amount of fees paid to insurance company	USD $2,716
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,186
Amount paid for insurance broker fees	1330
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5966325

Policy instance

Insurance contract or identification number	5966325
Number of Individuals Covered	220
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,072
Total amount of fees paid to insurance company	USD $5,126
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,548
Amount paid for insurance broker fees	192
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	136
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $80,092
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	80092
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

G 164899

Policy instance

Insurance contract or identification number	G 164899
Number of Individuals Covered	78
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,323
Total amount of fees paid to insurance company	USD $1,773
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,323
Insurance broker organization code?	3
Amount paid for insurance broker fees	1773
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

VPS 327101

Policy instance

Insurance contract or identification number	VPS 327101
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 $1,430
Total amount of fees paid to insurance company	USD $762
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,430
Insurance broker organization code?	3
Amount paid for insurance broker fees	762
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

VPL 302142

Policy instance

Insurance contract or identification number	VPL 302142
Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,521
Total amount of fees paid to insurance company	USD $811
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,521
Insurance broker organization code?	3
Amount paid for insurance broker fees	811
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	234
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,176
Total amount of fees paid to insurance company	USD $627
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,176
Insurance broker organization code?	3
Amount paid for insurance broker fees	627
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

GL 155981

Policy instance

Insurance contract or identification number	GL 155981
Number of Individuals Covered	51
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,036
Total amount of fees paid to insurance company	USD $1,620
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,036
Insurance broker organization code?	3
Amount paid for insurance broker fees	1620
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	104
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $5,344
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5344
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 207014

Policy instance

Insurance contract or identification number	VAR 207014
Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $540
Total amount of fees paid to insurance company	USD $216
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $540
Insurance broker organization code?	3
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES

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

Policy contract number

9475618

Policy instance

Insurance contract or identification number	9475618
Number of Individuals Covered	135
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $21,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

9475618

Policy instance

Insurance contract or identification number	9475618
Number of Individuals Covered	142
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $22,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G 164899

Policy instance

Insurance contract or identification number	G 164899
Number of Individuals Covered	78
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,087
Total amount of fees paid to insurance company	USD $1,407
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,087
Amount paid for insurance broker fees	294
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VPS 327101

Policy instance

Insurance contract or identification number	VPS 327101
Number of Individuals Covered	25
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,634
Total amount of fees paid to insurance company	USD $1,078
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,634
Amount paid for insurance broker fees	206
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VPL 302142

Policy instance

Insurance contract or identification number	VPL 302142
Number of Individuals Covered	23
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,897
Total amount of fees paid to insurance company	USD $1,240
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,897
Amount paid for insurance broker fees	228
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	243
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $847
Total amount of fees paid to insurance company	USD $582
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $847
Amount paid for insurance broker fees	130
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

GL 155981

Policy instance

Insurance contract or identification number	GL 155981
Number of Individuals Covered	46
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,151
Total amount of fees paid to insurance company	USD $1,395
Life Insurance Welfare Benefit	Yes
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
Commission paid to Insurance Broker	USD $2,151
Amount paid for insurance broker fees	248
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 207014

Policy instance

Insurance contract or identification number	VAR 207014
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $353
Total amount of fees paid to insurance company	USD $187
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $353
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	138
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $86,581
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	86581
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	101
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $5,534
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5534
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	97
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,671
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	4671
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

947-4923

Policy instance

Insurance contract or identification number	947-4923
Number of Individuals Covered	145
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $24,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VAR 207014

Policy instance

Insurance contract or identification number	VAR 207014
Number of Individuals Covered	18
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $276
Total amount of fees paid to insurance company	USD $112
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $276
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

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

Policy contract number

GL 155981

Policy instance

Insurance contract or identification number	GL 155981
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,485
Total amount of fees paid to insurance company	USD $811
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,902
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	19
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

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

Policy contract number

GL 155982

Policy instance

Insurance contract or identification number	GL 155982
Number of Individuals Covered	253
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,121
Total amount of fees paid to insurance company	USD $641
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,121
Amount paid for insurance broker fees	43
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	148
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $85,878
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	85878
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

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

Policy contract number

G 164899

Policy instance

Insurance contract or identification number	G 164899
Number of Individuals Covered	84
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,506
Total amount of fees paid to insurance company	USD $1,433
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,506
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

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

Policy contract number

VPS 327101

Policy instance

Insurance contract or identification number	VPS 327101
Number of Individuals Covered	23
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,234
Total amount of fees paid to insurance company	USD $671
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,226
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
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

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

Policy contract number

VPL 302142

Policy instance

Insurance contract or identification number	VPL 302142
Number of Individuals Covered	22
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,365
Total amount of fees paid to insurance company	USD $742
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,365
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	GROUP SOLUTIONS LLC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	136
Insurance policy start date	2015-01-01
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 $70,448
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	70448
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	96
Insurance policy start date	2015-01-01
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 $4,147
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4147
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-0742

Policy instance

Insurance contract or identification number	949-0742
Number of Individuals Covered	134
Insurance policy start date	2015-01-01
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 $0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $21,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	66
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $1,464
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,388
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	175
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $1,283
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,220
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	113
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $57,895
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	57895
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	160
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,053
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,053
Insurance broker organization code?	3
Insurance broker name	TRICOR INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	59
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,254
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,254
Insurance broker organization code?	3
Insurance broker name	TRICOR INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-7698

Policy instance

Insurance contract or identification number	949-7698
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $18,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

707

Policy instance

Insurance contract or identification number	707
Number of Individuals Covered	76
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,119
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3119
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	58
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,273
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,273
Insurance broker organization code?	3
Insurance broker name	TRICOR INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

139772

Policy instance

Insurance contract or identification number	139772
Number of Individuals Covered	153
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,066
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,066
Insurance broker organization code?	3
Insurance broker name	TRICOR INC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

00035088

Policy instance

Insurance contract or identification number	00035088
Number of Individuals Covered	208
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $30,676
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $625,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,498
Insurance broker organization code?	3
Insurance broker name	TRUE NORTH COMPANIES LC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

00035088

Policy instance

Insurance contract or identification number	00035088
Number of Individuals Covered	100
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $30,307
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $571,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,307
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INSURANCE SERVICES LLC

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Company Name:	HARTIG DRUG COMPANY
Employer identification number (EIN):	420298860
NAIC Classification:	446110
NAIC Description:	Pharmacies and Drug Stores

Jurisdiction of Incorporation:	Iowa Secretary of State Business Entities
Incorporation Date:	1917-02-24
Company Identification Number:	017939
Legal Registered Office Address:	703 MAIN ST DUBUQUE United States of America (USA) 52001

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01
501	2021-01-01	CARRIE TEMPERLY	2022-06-13
501	2021-01-01
501	2020-01-01	CHARLIE HARTIG	2021-10-11
501	2019-01-01	DICK HARTIG	2020-05-21
501	2018-01-01	DICK HARTIG	2019-09-24
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	MARILYN KAMMILLER
501	2011-01-01	MARILYN KAMMILLER