401k Plan data: SIOUX CENTER HEALTH WRAP PLAN plan

SIOUX CENTER HEALTH WRAP PLAN 401k Plan overview

Plan Name	SIOUX CENTER HEALTH WRAP PLAN
Plan identification number	501

SIOUX CENTER HEALTH WRAP PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

SIOUX CENTER HEALTH has sponsored the creation of one or more 401k plans.

Company Name: SIOUX CENTER HEALTH

Employer identification number (EIN): 420796764

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about SIOUX CENTER HEALTH

Jurisdiction of Incorporation: Iowa Secretary of State Business Entities

Incorporation Date: 1948-01-27

Company Identification Number: 081856

Legal Registered Office Address: 1101 9TH ST SE

SIOUX CENTER
United States of America (USA)
51250

More information about SIOUX CENTER HEALTH

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SIOUX CENTER HEALTH WRAP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 THERESA TUCKER 2023-07-26 CRYSTAL RICHTER 2023-07-26
501 2021-01-01 THERESA TUCKER 2022-07-12 CRYSTAL RICHTER 2022-07-12
501 2020-01-01 THERESA TUCKER 2021-07-26 KARI TIMMER 2021-07-26
501 2019-01-01 THERESA TUCKER 2020-07-30 KARI TIMMER 2020-08-04
501 2018-07-01
501 2017-07-01
501 2016-07-01
501 2015-07-01
501 2014-07-01
501 2013-07-01
501 2012-07-01 JACKSON SHUITEMAN
501 2011-07-01 THERESA TUCKER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	THERESA TUCKER	2023-07-26	CRYSTAL RICHTER	2023-07-26
501	2021-01-01	THERESA TUCKER	2022-07-12	CRYSTAL RICHTER	2022-07-12
501	2020-01-01	THERESA TUCKER	2021-07-26	KARI TIMMER	2021-07-26
501	2019-01-01	THERESA TUCKER	2020-07-30	KARI TIMMER	2020-08-04
501	2018-07-01
501	2017-07-01
501	2016-07-01
501	2015-07-01
501	2014-07-01
501	2013-07-01
501	2012-07-01	JACKSON SHUITEMAN
501	2011-07-01	THERESA TUCKER

Plan Statistics for SIOUX CENTER HEALTH WRAP PLAN

401k plan membership statisitcs for SIOUX CENTER HEALTH WRAP PLAN

Measure Date Value
2022: SIOUX CENTER HEALTH WRAP PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 225
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 2022-01-01 225
2021: SIOUX CENTER HEALTH WRAP PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 219
Number of retired or separated participants receiving benefits 2021-01-01 3
Number of other retired or separated participants entitled to future benefits 2021-01-01 63
Total of all active and inactive participants 2021-01-01 285
2020: SIOUX CENTER HEALTH WRAP PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 213
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 213
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 7
Total of all active and inactive participants 2020-01-01 221
2019: SIOUX CENTER HEALTH WRAP PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 226
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 213
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 215
2018: SIOUX CENTER HEALTH WRAP PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 263
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 219
Number of retired or separated participants receiving benefits 2018-07-01 7
Total of all active and inactive participants 2018-07-01 226
2017: SIOUX CENTER HEALTH WRAP PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 277
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 263
Total of all active and inactive participants 2017-07-01 263
2016: SIOUX CENTER HEALTH WRAP PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 271
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 248
Number of retired or separated participants receiving benefits 2016-07-01 1
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 249
2015: SIOUX CENTER HEALTH WRAP PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 204
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 214
Number of retired or separated participants receiving benefits 2015-07-01 3
Total of all active and inactive participants 2015-07-01 217
2014: SIOUX CENTER HEALTH WRAP PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 195
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 204
Number of retired or separated participants receiving benefits 2014-07-01 0
Number of other retired or separated participants entitled to future benefits 2014-07-01 5
Total of all active and inactive participants 2014-07-01 209
2013: SIOUX CENTER HEALTH WRAP PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 195
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 192
Number of retired or separated participants receiving benefits 2013-07-01 2
Number of other retired or separated participants entitled to future benefits 2013-07-01 2
Total of all active and inactive participants 2013-07-01 196
2012: SIOUX CENTER HEALTH WRAP PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 200
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 197
Number of retired or separated participants receiving benefits 2012-07-01 3
Total of all active and inactive participants 2012-07-01 200
2011: SIOUX CENTER HEALTH WRAP PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 200
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 197
Number of retired or separated participants receiving benefits 2011-07-01 4
Total of all active and inactive participants 2011-07-01 201

Measure	Date	Value
2022: SIOUX CENTER HEALTH WRAP PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	225
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	225
2021: SIOUX CENTER HEALTH WRAP PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	219
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	63
Total of all active and inactive participants	2021-01-01	285
2020: SIOUX CENTER HEALTH WRAP PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	213
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	213
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	7
Total of all active and inactive participants	2020-01-01	221
2019: SIOUX CENTER HEALTH WRAP PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	226
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	213
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	215
2018: SIOUX CENTER HEALTH WRAP PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	263
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	219
Number of retired or separated participants receiving benefits	2018-07-01	7
Total of all active and inactive participants	2018-07-01	226
2017: SIOUX CENTER HEALTH WRAP PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	277
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	263
Total of all active and inactive participants	2017-07-01	263
2016: SIOUX CENTER HEALTH WRAP PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	271
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	248
Number of retired or separated participants receiving benefits	2016-07-01	1
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	249
2015: SIOUX CENTER HEALTH WRAP PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	204
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	214
Number of retired or separated participants receiving benefits	2015-07-01	3
Total of all active and inactive participants	2015-07-01	217
2014: SIOUX CENTER HEALTH WRAP PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	195
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	204
Number of retired or separated participants receiving benefits	2014-07-01	0
Number of other retired or separated participants entitled to future benefits	2014-07-01	5
Total of all active and inactive participants	2014-07-01	209
2013: SIOUX CENTER HEALTH WRAP PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	195
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	192
Number of retired or separated participants receiving benefits	2013-07-01	2
Number of other retired or separated participants entitled to future benefits	2013-07-01	2
Total of all active and inactive participants	2013-07-01	196
2012: SIOUX CENTER HEALTH WRAP PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	200
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	197
Number of retired or separated participants receiving benefits	2012-07-01	3
Total of all active and inactive participants	2012-07-01	200
2011: SIOUX CENTER HEALTH WRAP PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	200
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	197
Number of retired or separated participants receiving benefits	2011-07-01	4
Total of all active and inactive participants	2011-07-01	201

Form 5500 Responses for SIOUX CENTER HEALTH WRAP PLAN

2022: SIOUX CENTER HEALTH WRAP PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
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: SIOUX CENTER HEALTH WRAP PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
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: SIOUX CENTER HEALTH WRAP PLAN 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: SIOUX CENTER HEALTH WRAP PLAN 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: SIOUX CENTER HEALTH WRAP PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: SIOUX CENTER HEALTH WRAP PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: SIOUX CENTER HEALTH WRAP PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: SIOUX CENTER HEALTH WRAP PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: SIOUX CENTER HEALTH WRAP PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: SIOUX CENTER HEALTH WRAP PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: SIOUX CENTER HEALTH WRAP PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: SIOUX CENTER HEALTH WRAP PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	First time form 5500 has been submitted	Yes
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00573669

Policy instance

Insurance contract or identification number	00573669
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 $1,738
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,721
Insurance broker organization code?	3

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	225
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,928
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,928
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,814
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $19,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,281
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	33
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,407
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $13,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,178
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,878
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $629
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	65
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,988
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,425
Insurance broker organization code?	3

LIFESECURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77720 )

Policy contract number

01649V

Policy instance

Insurance contract or identification number	01649V
Number of Individuals Covered	27
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,646
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $36,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,550
Insurance broker organization code?	3

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

1803

Policy instance

Insurance contract or identification number	1803
Number of Individuals Covered	225
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $49,939
Total amount of fees paid to insurance company	USD $68,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,657
Amount paid for insurance broker fees	68475
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	187
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,837
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,837
Insurance broker organization code?	3

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

Policy contract number

167028

Policy instance

Insurance contract or identification number	167028
Number of Individuals Covered	18
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,636
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,509
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

40869

Policy instance

Insurance contract or identification number	40869
Number of Individuals Covered	221
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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

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

Policy contract number

2004169

Policy instance

Insurance contract or identification number	2004169
Number of Individuals Covered	484
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,396
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSURE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $23,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,396
Insurance broker organization code?	3

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

Policy contract number

131099

Policy instance

Insurance contract or identification number	131099
Number of Individuals Covered	282
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,247
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,398
Insurance broker organization code?	3

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

RF052173

Policy instance

Insurance contract or identification number	RF052173
Number of Individuals Covered	135
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $178,828
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PROACTIVE HEALTH MANAGMENT PLAN
Welfare Benefit Premiums Paid to Carrier	USD $974,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $160,528
Insurance broker organization code?	5

LIFESECURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77720 )

Policy contract number

01649V

Policy instance

Insurance contract or identification number	01649V
Number of Individuals Covered	27
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,259
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $36,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,204
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	62
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,926
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,993
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	43
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,980
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $10,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $692
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	27
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,485
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $11,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $859
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	48
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,483
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Insurance broker organization code?	3

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	357
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,899
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,899
Insurance broker organization code?	3

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

1803

Policy instance

Insurance contract or identification number	1803
Number of Individuals Covered	219
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $45,354
Total amount of fees paid to insurance company	USD $65,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,504
Amount paid for insurance broker fees	65200
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	181
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,750
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,750
Insurance broker organization code?	3

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

Policy contract number

167028

Policy instance

Insurance contract or identification number	167028
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,249
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,199
Insurance broker organization code?	3

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

Policy contract number

00573669

Policy instance

Insurance contract or identification number	00573669
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,559
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,533
Insurance broker organization code?	3

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

RF052173

Policy instance

Insurance contract or identification number	RF052173
Number of Individuals Covered	106
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $161,116
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PROACTIVE HEALTH MANAGMENT PLAN
Welfare Benefit Premiums Paid to Carrier	USD $878,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $141,331
Insurance broker organization code?	5

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

Policy contract number

131099

Policy instance

Insurance contract or identification number	131099
Number of Individuals Covered	285
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $13,581
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,865
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

052173

Policy instance

Insurance contract or identification number	052173
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

2004169

Policy instance

Insurance contract or identification number	2004169
Number of Individuals Covered	441
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,257
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MANAGED ORGAN/TISSURE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $22,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,257
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

40869

Policy instance

Insurance contract or identification number	40869
Number of Individuals Covered	220
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	39
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,099
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,463
Insurance broker organization code?	3

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

Policy contract number

131099

Policy instance

Insurance contract or identification number	131099
Number of Individuals Covered	278
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,131
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,505
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

052173

Policy instance

Insurance contract or identification number	052173
Number of Individuals Covered	103
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $230,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

2004169

Policy instance

Insurance contract or identification number	2004169
Number of Individuals Covered	444
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 $2,213
Other welfare benefits provided	MANAGED ORGAN/TISSURE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $22,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2213
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

40869

Policy instance

Insurance contract or identification number	40869
Number of Individuals Covered	214
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

167028

Policy instance

Insurance contract or identification number	167028
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 $5,152
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,122
Insurance broker organization code?	3

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	352
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,671
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,671
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	29
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,564
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $10,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $550
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,712
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $9,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $603
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	52
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,129
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,445
Insurance broker organization code?	3

LIFESECURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77720 )

Policy contract number

01649V

Policy instance

Insurance contract or identification number	01649V
Number of Individuals Covered	30
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,381
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $36,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,299
Insurance broker organization code?	3

QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )

Policy contract number

1803

Policy instance

Insurance contract or identification number	1803
Number of Individuals Covered	213
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $44,599
Total amount of fees paid to insurance company	USD $63,325
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	63325
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	186
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,767
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,767
Insurance broker organization code?	3

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	345
Insurance policy start date	2019-07-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,011
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,011
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	28
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,272
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $11,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $798
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	48
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,655
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $11,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $584
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	48
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,014
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,405
Insurance broker organization code?	3

LIFESECURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77720 )

Policy contract number

01649V

Policy instance

Insurance contract or identification number	01649V
Number of Individuals Covered	33
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,593
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $44,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,813
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
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 $2,801
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $985
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	177
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,674
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,674
Insurance broker organization code?	3

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

1803

Policy instance

Insurance contract or identification number	1803
Number of Individuals Covered	213
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $39,560
Total amount of fees paid to insurance company	USD $69,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	69100
Additional information about fees paid to insurance broker	BROKER FEE
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $39,560

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000ALLE

Policy instance

Insurance contract or identification number	G000ALLE
Number of Individuals Covered	262
Insurance policy start date	2018-04-01
Insurance policy end date	2019-04-01
Total amount of commissions paid to insurance broker	USD $4,691
Total amount of fees paid to insurance company	USD $5,525
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,691
Amount paid for insurance broker fees	5525
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	347
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $822
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $822
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

1803

Policy instance

Insurance contract or identification number	1803
Number of Individuals Covered	221
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $41,070
Total amount of fees paid to insurance company	USD $66,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	66075
Additional information about fees paid to insurance broker	BROKER FEE
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $41,070

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	176
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,469
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,469
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	52
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,656
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,630
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	32
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,335
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,516
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	76
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,897
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,717
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

32544

Policy instance

Insurance contract or identification number	32544
Number of Individuals Covered	55
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,491
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,271
Insurance broker organization code?	3

LIFESECURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77720 )

Policy contract number

01649V

Policy instance

Insurance contract or identification number	01649V
Number of Individuals Covered	45
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,971
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $29,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,581
Insurance broker organization code?	3

GROUP RESOURCES OF IOWA DBA THREE RIVERS BENEFITS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

Policy instance

Number of Individuals Covered	221
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,606
Total amount of fees paid to insurance company	USD $16,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,606
Amount paid for insurance broker fees	16570
Insurance broker organization code?	5
Insurance broker name	GROUP RESOURCES OF IOWA

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000ALLE

Policy instance

Insurance contract or identification number	G000ALLE
Number of Individuals Covered	256
Insurance policy start date	2017-04-01
Insurance policy end date	2018-04-01
Total amount of commissions paid to insurance broker	USD $4,110
Total amount of fees paid to insurance company	USD $4,408
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,110
Amount paid for insurance broker fees	4408
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30036082

Policy instance

Insurance contract or identification number	30036082
Number of Individuals Covered	167
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,484
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,929
Insurance broker organization code?	3
Insurance broker name	ZEUTENHORST FINANCIAL

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

Policy contract number

00002120

Policy instance

Insurance contract or identification number	00002120
Number of Individuals Covered	212
Insurance policy start date	2017-07-01
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMC NATIONAL LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 62928 )

Policy contract number

GL0900

Policy instance

Insurance contract or identification number	GL0900
Number of Individuals Covered	263
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,694
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,116
Insurance broker organization code?	3
Insurance broker name	THE ACHIEVEMENT GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000ALLE

Policy instance

Insurance contract or identification number	G000ALLE
Number of Individuals Covered	14
Insurance policy start date	2017-04-01
Insurance policy end date	2018-04-01
Total amount of commissions paid to insurance broker	USD $1,342
Total amount of fees paid to insurance company	USD $1,472
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,342
Amount paid for insurance broker fees	1472
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

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

Policy contract number

00002120

Policy instance

Insurance contract or identification number	00002120
Number of Individuals Covered	212
Insurance policy start date	2017-07-01
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,431,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SIOUX CENTER HEALTH
Employer identification number (EIN):	420796764
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	Iowa Secretary of State Business Entities
Incorporation Date:	1948-01-27
Company Identification Number:	081856
Legal Registered Office Address:	1101 9TH ST SE SIOUX CENTER United States of America (USA) 51250