401k Plan data: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN plan

XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 401k Plan overview

Plan Name	XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN
Plan identification number	501

XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: XCELLENCE, INC.

Employer identification number (EIN): 431685216

NAIC Classification: 561410
NAIC Description: Document Preparation Services

Additional information about XCELLENCE, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2005-04-01

Company Identification Number: 0800476757

Legal Registered Office Address: 1828 L ST NW STE 1070

WASHINGTON
United States of America (USA)
20036

More information about XCELLENCE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01
501 2019-01-01
501 2018-01-01 KERI GRIMMETT KERI GRIMMETT 2019-06-13
501 2017-01-01 KERI GRIMMETT KERI GRIMMETT 2018-05-21
501 2016-01-01 KERI GRIMMETT KERI GRIMMETT 2017-06-12
501 2015-01-01 RACQUEL SERRANO RACQUEL SERRANO 2016-07-25
501 2014-01-01 RACQUEL SERRANO RACQUEL SERRANO 2015-07-02
501 2013-01-01 RACQUEL SERRANO RACQUEL SERRANO 2015-07-02
501 2012-01-01 KERI GRIMMETT KERI GRIMMETT 2013-08-02

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2020-01-01
501	2019-01-01
501	2018-01-01	KERI GRIMMETT	KERI GRIMMETT	2019-06-13
501	2017-01-01	KERI GRIMMETT	KERI GRIMMETT	2018-05-21
501	2016-01-01	KERI GRIMMETT	KERI GRIMMETT	2017-06-12
501	2015-01-01	RACQUEL SERRANO	RACQUEL SERRANO	2016-07-25
501	2014-01-01	RACQUEL SERRANO	RACQUEL SERRANO	2015-07-02
501	2013-01-01	RACQUEL SERRANO	RACQUEL SERRANO	2015-07-02
501	2012-01-01	KERI GRIMMETT	KERI GRIMMETT	2013-08-02

Plan Statistics for XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN

401k plan membership statisitcs for XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN

Measure Date Value
2020: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 251
Number of retired or separated participants receiving benefits 2020-01-01 4
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 255
2019: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 192
Number of retired or separated participants receiving benefits 2019-01-01 3
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 195
2018: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 172
Number of retired or separated participants receiving benefits 2018-01-01 6
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 178
2017: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 157
Number of retired or separated participants receiving benefits 2017-01-01 2
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 159
2016: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 142
Number of retired or separated participants receiving benefits 2016-01-01 2
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 144
2015: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 141
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 2015-01-01 141
2014: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 135
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 135
2013: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 139
Total of all active and inactive participants 2013-01-01 139
2012: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 139
Total of all active and inactive participants 2012-01-01 139

Measure	Date	Value
2020: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	251
Number of retired or separated participants receiving benefits	2020-01-01	4
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	255
2019: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	192
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	195
2018: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	172
Number of retired or separated participants receiving benefits	2018-01-01	6
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	178
2017: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	157
Number of retired or separated participants receiving benefits	2017-01-01	2
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	159
2016: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	142
Number of retired or separated participants receiving benefits	2016-01-01	2
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	144
2015: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	141
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	141
2014: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	135
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	135
2013: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	139
Total of all active and inactive participants	2013-01-01	139
2012: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	139
Total of all active and inactive participants	2012-01-01	139

Form 5500 Responses for XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN

2020: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS 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: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS 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: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 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: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 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: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 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 benefit arrangement – Insurance	Yes
2015: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 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 benefit arrangement – Insurance	Yes
2014: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 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: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: XCELLENCE, INC. DBA XACT DATA DISCOVERY GROUP BENEFITS WRAP PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

VAR 207368

Policy instance

Insurance contract or identification number	VAR 207368
Number of Individuals Covered	144
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,211
Total amount of fees paid to insurance company	USD $43
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,211
Insurance broker organization code?	3
Amount paid for insurance broker fees	43
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	513
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $87,508
Total amount of fees paid to insurance company	USD $27,180
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 $87,508
Amount paid for insurance broker fees	27180
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-01

Policy instance

Insurance contract or identification number	53308-01
Number of Individuals Covered	170
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,392
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,392
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-02

Policy instance

Insurance contract or identification number	53308-02
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10093401001

Policy instance

Insurance contract or identification number	10093401001
Number of Individuals Covered	311
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,437
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,437
Insurance broker organization code?	3

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

Policy contract number

GL 157309

Policy instance

Insurance contract or identification number	GL 157309
Number of Individuals Covered	210
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,759
Total amount of fees paid to insurance company	USD $385
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $41,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,759
Insurance broker organization code?	3
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

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

Policy contract number

G 165400

Policy instance

Insurance contract or identification number	G 165400
Number of Individuals Covered	210
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,911
Total amount of fees paid to insurance company	USD $558
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,911
Insurance broker organization code?	3
Amount paid for insurance broker fees	558
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

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

Policy contract number

LTD 128542

Policy instance

Insurance contract or identification number	LTD 128542
Number of Individuals Covered	211
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,701
Total amount of fees paid to insurance company	USD $266
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,701
Insurance broker organization code?	3
Amount paid for insurance broker fees	266
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	391
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $66,754
Total amount of fees paid to insurance company	USD $20,664
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 $66,754
Amount paid for insurance broker fees	20664
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-01

Policy instance

Insurance contract or identification number	53308-01
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 $7,664
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,664
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-02

Policy instance

Insurance contract or identification number	53308-02
Number of Individuals Covered	3
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10093401001

Policy instance

Insurance contract or identification number	10093401001
Number of Individuals Covered	217
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,566
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,566
Insurance broker organization code?	3

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

Policy contract number

GL 157309

Policy instance

Insurance contract or identification number	GL 157309
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,928
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,928
Insurance broker organization code?	3

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

Policy contract number

G 165400

Policy instance

Insurance contract or identification number	G 165400
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,701
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,701
Insurance broker organization code?	3

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

Policy contract number

LTD 128542

Policy instance

Insurance contract or identification number	LTD 128542
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,197
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,197
Insurance broker organization code?	3

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

Policy contract number

VAR 207368

Policy instance

Insurance contract or identification number	VAR 207368
Number of Individuals Covered	65
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $689
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $689
Insurance broker organization code?	3

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	375
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $60,049
Total amount of fees paid to insurance company	USD $18,495
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 $60,049
Amount paid for insurance broker fees	18495
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-01

Policy instance

Insurance contract or identification number	53308-01
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 $7,421
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,421
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10093401001

Policy instance

Insurance contract or identification number	10093401001
Number of Individuals Covered	220
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,667
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,667
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-02

Policy instance

Insurance contract or identification number	53308-02
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,267
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

GL 157309

Policy instance

Insurance contract or identification number	GL 157309
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,153
Total amount of fees paid to insurance company	USD $653
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $26,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,153
Amount paid for insurance broker fees	481
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

G 165400

Policy instance

Insurance contract or identification number	G 165400
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,817
Total amount of fees paid to insurance company	USD $1,604
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,817
Amount paid for insurance broker fees	1182
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

LTD 128542

Policy instance

Insurance contract or identification number	LTD 128542
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,651
Total amount of fees paid to insurance company	USD $721
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,651
Amount paid for insurance broker fees	531
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 207368

Policy instance

Insurance contract or identification number	VAR 207368
Number of Individuals Covered	47
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $412
Total amount of fees paid to insurance company	USD $69
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $412
Amount paid for insurance broker fees	51
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

LTD 128542

Policy instance

Insurance contract or identification number	LTD 128542
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,276
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,276
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

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

Policy contract number

G 165400

Policy instance

Insurance contract or identification number	G 165400
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,064
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,064
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

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

Policy contract number

GL 157309

Policy instance

Insurance contract or identification number	GL 157309
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,201
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $22,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,201
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10093401

Policy instance

Insurance contract or identification number	10093401
Number of Individuals Covered	203
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,416
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,416
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-02

Policy instance

Insurance contract or identification number	53308-02
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

53308-01

Policy instance

Insurance contract or identification number	53308-01
Number of Individuals Covered	143
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,235
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,235
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	358
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $59,466
Total amount of fees paid to insurance company	USD $15,920
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 $59,466
Amount paid for insurance broker fees	15920
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEES NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	194
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $46,198
Total amount of fees paid to insurance company	USD $12,030
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid in cash?	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 $11,483
Amount paid for insurance broker fees	3700
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	199
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,980
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $997
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

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

Policy contract number

575810

Policy instance

Insurance contract or identification number	575810
Number of Individuals Covered	64
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $763
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $139
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCY AGENCY

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	133
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,184
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $819
Insurance broker organization code?	5
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	141
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,449
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $414
Insurance broker organization code?	5
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	141
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,904
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $830
Insurance broker organization code?	5
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,335
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $934
Insurance broker organization code?	5
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	38
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $140
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56
Insurance broker organization code?	5
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	195
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $38,286
Total amount of fees paid to insurance company	USD $14,060
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 $38,286
Amount paid for insurance broker fees	14060
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

36664000

Policy instance

Insurance contract or identification number	36664000
Number of Individuals Covered	210
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,896
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,896
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

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

Policy contract number

575810

Policy instance

Insurance contract or identification number	575810
Number of Individuals Covered	61
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $660
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $660
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	135
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $166
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62
Insurance broker organization code?	5
Insurance broker name	THE HAYS GROUP OF KANSAS CITY, LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	120
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $296
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111
Insurance broker organization code?	5
Insurance broker name	THE HAYS GROUP OF KANSAS CITY, LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	135
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $237
Long Term Disability Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid in cash?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	5
Insurance broker name	THE HAYS GROUP OF KANSAS CITY, LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	40
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $206
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82
Insurance broker organization code?	5
Insurance broker name	THE HAYS GROUP OF KANSAS CITY, LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50019707

Policy instance

Insurance contract or identification number	50019707
Number of Individuals Covered	47
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,472
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $989
Insurance broker organization code?	5
Insurance broker name	THE HAYS GROUP OF KANSAS CITY, LLC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	139
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,008
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-43
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP OF KANSAS CITY

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

Policy contract number

743581

Policy instance

Insurance contract or identification number	743581
Number of Individuals Covered	182
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $36,332
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $727,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,838
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	139
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,166
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP OF KANSAS CITY

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	132
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,722
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,722
Insurance broker organization code?	3
Insurance broker name	HALLIER REED, LLC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	121
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,203
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP OF KANSAS CITY

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	122
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,014
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,142
Commission paid to Insurance Broker	USD $1,014
Insurance broker organization code?	3
Insurance broker name	HALLIER REED LLC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	138
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,011
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,740
Commission paid to Insurance Broker	USD $1,011
Insurance broker organization code?	3
Insurance broker name	HALLIER REED LLC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

740B93

Policy instance

Insurance contract or identification number	740B93
Number of Individuals Covered	177
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,051
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $43,580
Commission paid to Insurance Broker	USD $3,051
Insurance broker organization code?	3
Insurance broker name	HALLIER REED LLC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

940B93

Policy instance

Insurance contract or identification number	940B93
Number of Individuals Covered	139
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $865
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $5,767
Commission paid to Insurance Broker	USD $865
Insurance broker organization code?	3
Insurance broker name	HALLIER REED LLC

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Company Name:	XCELLENCE, INC.
Employer identification number (EIN):	431685216
NAIC Classification:	561410
NAIC Description:	Document Preparation Services

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2005-04-01
Company Identification Number:	0800476757
Legal Registered Office Address:	1828 L ST NW STE 1070 WASHINGTON United States of America (USA) 20036