401k Plan data: ALBERICI GROUP INC. FRINGE BENEFIT PLAN plan

ALBERICI GROUP INC. FRINGE BENEFIT PLAN 401k Plan overview

Plan Name	ALBERICI GROUP INC. FRINGE BENEFIT PLAN
Plan identification number	501

ALBERICI GROUP INC. FRINGE BENEFIT 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) Prepaid legal Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

ALBERICI GROUP INC. has sponsored the creation of one or more 401k plans.

Company Name: ALBERICI GROUP INC.

Employer identification number (EIN): 431907310

NAIC Classification: 561110
NAIC Description: Office Administrative Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ALBERICI GROUP INC. FRINGE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 R. DENAY DAVIS 2023-09-28
501 2021-01-01 R. DENAY DAVIS 2022-09-25
501 2020-01-01 R. DENAY DAVIS 2021-07-23
501 2019-01-01 R. DENAY DAVIS 2020-09-24 RICHARD JAGGERS 2020-09-24
501 2018-01-01 R. DENAY DAVIS 2019-10-07 RICHARD JAGGERS 2019-10-07
501 2017-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 R. DENAY DAVIS
501 2011-01-01 R. DENAY DAVIS
501 2009-01-01 R. DENAY DAVIS
501 2009-01-01 R. DENAY DAVIS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	R. DENAY DAVIS	2023-09-28
501	2021-01-01	R. DENAY DAVIS	2022-09-25
501	2020-01-01	R. DENAY DAVIS	2021-07-23
501	2019-01-01	R. DENAY DAVIS	2020-09-24	RICHARD JAGGERS	2020-09-24
501	2018-01-01	R. DENAY DAVIS	2019-10-07	RICHARD JAGGERS	2019-10-07
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	R. DENAY DAVIS
501	2011-01-01	R. DENAY DAVIS
501	2009-01-01	R. DENAY DAVIS
501	2009-01-01	R. DENAY DAVIS

Plan Statistics for ALBERICI GROUP INC. FRINGE BENEFIT PLAN

401k plan membership statisitcs for ALBERICI GROUP INC. FRINGE BENEFIT PLAN

Measure Date Value
2022: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 394
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 406
Number of retired or separated participants receiving benefits 2022-01-01 8
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 414
2021: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 315
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 384
Number of retired or separated participants receiving benefits 2021-01-01 10
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 394
2020: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 309
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 308
Number of retired or separated participants receiving benefits 2020-01-01 7
Total of all active and inactive participants 2020-01-01 315
2019: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 309
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 304
Number of retired or separated participants receiving benefits 2019-01-01 5
Total of all active and inactive participants 2019-01-01 309
2018: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 307
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 303
Number of retired or separated participants receiving benefits 2018-01-01 6
Total of all active and inactive participants 2018-01-01 309
2017: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 311
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 299
Number of retired or separated participants receiving benefits 2017-01-01 8
Total of all active and inactive participants 2017-01-01 307
2016: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 292
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 303
Number of retired or separated participants receiving benefits 2016-01-01 8
Total of all active and inactive participants 2016-01-01 311
2015: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 271
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 292
Number of retired or separated participants receiving benefits 2015-01-01 5
Total of all active and inactive participants 2015-01-01 297
2014: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 340
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 267
Number of retired or separated participants receiving benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 271
2013: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 359
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 266
Number of retired or separated participants receiving benefits 2013-01-01 74
Total of all active and inactive participants 2013-01-01 340
2012: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 331
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 280
Number of retired or separated participants receiving benefits 2012-01-01 79
Total of all active and inactive participants 2012-01-01 359
2011: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 306
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 326
Number of retired or separated participants receiving benefits 2011-01-01 5
Total of all active and inactive participants 2011-01-01 331
2009: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 334
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 286
Number of retired or separated participants receiving benefits 2009-01-01 29
Total of all active and inactive participants 2009-01-01 315

Measure	Date	Value
2022: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	394
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	406
Number of retired or separated participants receiving benefits	2022-01-01	8
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	414
2021: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	315
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	384
Number of retired or separated participants receiving benefits	2021-01-01	10
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	394
2020: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	309
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	308
Number of retired or separated participants receiving benefits	2020-01-01	7
Total of all active and inactive participants	2020-01-01	315
2019: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	309
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	304
Number of retired or separated participants receiving benefits	2019-01-01	5
Total of all active and inactive participants	2019-01-01	309
2018: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	307
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	303
Number of retired or separated participants receiving benefits	2018-01-01	6
Total of all active and inactive participants	2018-01-01	309
2017: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	311
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	299
Number of retired or separated participants receiving benefits	2017-01-01	8
Total of all active and inactive participants	2017-01-01	307
2016: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	292
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	303
Number of retired or separated participants receiving benefits	2016-01-01	8
Total of all active and inactive participants	2016-01-01	311
2015: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	271
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	292
Number of retired or separated participants receiving benefits	2015-01-01	5
Total of all active and inactive participants	2015-01-01	297
2014: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	267
Number of retired or separated participants receiving benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	271
2013: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	359
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	266
Number of retired or separated participants receiving benefits	2013-01-01	74
Total of all active and inactive participants	2013-01-01	340
2012: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	331
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	280
Number of retired or separated participants receiving benefits	2012-01-01	79
Total of all active and inactive participants	2012-01-01	359
2011: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	306
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	326
Number of retired or separated participants receiving benefits	2011-01-01	5
Total of all active and inactive participants	2011-01-01	331
2009: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	334
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	286
Number of retired or separated participants receiving benefits	2009-01-01	29
Total of all active and inactive participants	2009-01-01	315

Form 5500 Responses for ALBERICI GROUP INC. FRINGE BENEFIT PLAN

2022: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: ALBERICI GROUP INC. FRINGE BENEFIT 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: ALBERICI GROUP INC. FRINGE BENEFIT 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: ALBERICI GROUP INC. FRINGE BENEFIT 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: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
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: ALBERICI GROUP INC. FRINGE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ALBERICI GROUP INC. FRINGE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ALBERICI GROUP INC. FRINGE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: ALBERICI GROUP INC. FRINGE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ALBERICI GROUP INC. FRINGE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

XB754104

Policy instance

Insurance contract or identification number	XB754104
Number of Individuals Covered	34
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $34,237
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $105,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,803
Insurance broker organization code?	3

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

Policy contract number

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $241
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NONE
Insurance broker organization code?	3

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

21270000

Policy instance

Insurance contract or identification number	21270000
Number of Individuals Covered	871
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $270,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	394
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 $3,432
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $252,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	3432
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ETB154050

Policy instance

Insurance contract or identification number	ETB154050
Number of Individuals Covered	1231
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	314
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

571289

Policy instance

Insurance contract or identification number	571289
Number of Individuals Covered	61
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL SERVICES
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

NONE

Policy instance

Insurance contract or identification number	NONE
Number of Individuals Covered	395
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
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 $4,128
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	10
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $354
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140
Insurance broker organization code?	3

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

21270000

Policy instance

Insurance contract or identification number	21270000
Number of Individuals Covered	836
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $287,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	380
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 $3,642
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $188,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3642
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ETB154050

Policy instance

Insurance contract or identification number	ETB154050
Number of Individuals Covered	1564
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $2,206
Total amount of fees paid to insurance company	USD $221
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,206
Amount paid for insurance broker fees	221
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	269
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

00000978

Policy instance

Insurance contract or identification number	00000978
Number of Individuals Covered	348
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $609,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

NONE

Policy instance

Insurance contract or identification number	NONE
Number of Individuals Covered	379
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
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 $679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

XB754104

Policy instance

Insurance contract or identification number	XB754104
Number of Individuals Covered	29
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $16,921
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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 $80,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,550
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

571289

Policy instance

Insurance contract or identification number	571289
Number of Individuals Covered	61
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL SERVICES
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,029
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	15
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $446
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	324
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 $1,851
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $158,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1534
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	238
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	313
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
Welfare Benefit Premiums Paid to Carrier	USD $346,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Number of Individuals Covered	358
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $15,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

XB754104

Policy instance

Insurance contract or identification number	XB754104
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 $26,302
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,671
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

571289

Policy instance

Insurance contract or identification number	571289
Number of Individuals Covered	49
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $10,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

21270000

Policy instance

Insurance contract or identification number	21270000
Number of Individuals Covered	730
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
Welfare Benefit Premiums Paid to Carrier	USD $211,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $493
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $191
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	310
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,520
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $136,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1327
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

XB754104

Policy instance

Insurance contract or identification number	XB754104
Number of Individuals Covered	35
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $30,491
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,557
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

571289

Policy instance

Insurance contract or identification number	571289
Number of Individuals Covered	38
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $42
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $10,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

5412810010

Policy instance

Insurance contract or identification number	5412810010
Number of Individuals Covered	196
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

21270000

Policy instance

Insurance contract or identification number	21270000
Number of Individuals Covered	716
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $190,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Number of Individuals Covered	365
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $15,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	303
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $501,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	306
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,112
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $132,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2112
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	310
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $452,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

XB754104

Policy instance

Insurance contract or identification number	XB754104
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $23,655
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,109
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

571289

Policy instance

Insurance contract or identification number	571289
Number of Individuals Covered	35
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $9,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

5412810010

Policy instance

Insurance contract or identification number	5412810010
Number of Individuals Covered	173
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

21270000

Policy instance

Insurance contract or identification number	21270000
Number of Individuals Covered	734
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	18
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $512
Total amount of fees paid to insurance company	USD $1
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $196
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Number of Individuals Covered	316
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $7,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	299
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,077
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $131,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,077
Insurance broker organization code?	3
Insurance broker name	CONDUENT HR CONSULTING LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

#2ALB607

Policy instance

Insurance contract or identification number	#2ALB607
Number of Individuals Covered	160
Insurance policy start date	2017-01-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,354
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	20
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $623
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Insurance broker organization code?	3
Insurance broker name	CONDUENT HR CONSULTING LLC

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	303
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $622,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-9881

Policy instance

Insurance contract or identification number	9906-9881
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Total amount of commissions paid to insurance broker	USD $2,850
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,850
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Number of Individuals Covered	303
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $7,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GD3-84044407701

Policy instance

Insurance contract or identification number	GD3-84044407701
Number of Individuals Covered	69
Insurance policy start date	2016-06-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $458
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $20,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	458
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BUCK CONSULTANTS LLC

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-9881

Policy instance

Insurance contract or identification number	9906-9881
Insurance policy start date	2014-06-01
Insurance policy end date	2015-06-01
Total amount of commissions paid to insurance broker	USD $2,850
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,850
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	176
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $786,117
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	25
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $921
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $336
Insurance broker name	AMERICAN INS AGENCIES LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

#2ALB607

Policy instance

Insurance contract or identification number	#2ALB607
Number of Individuals Covered	155
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	297
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $131,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	BUCK CONSULTANTS LLC

PREFERRED RESOURCE NETWORK, INC. DBA PERSONAL ASSISTANCE SERVICES (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Number of Individuals Covered	303
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $7,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

#2ALB607

Policy instance

Insurance contract or identification number	#2ALB607
Number of Individuals Covered	141
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,950
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	27
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $983
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Insurance broker name	WARREN C DER

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	279
Insurance policy start date	2014-01-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-9881

Policy instance

Insurance contract or identification number	9906-9881
Insurance policy start date	2013-04-01
Insurance policy end date	2014-04-01
Total amount of commissions paid to insurance broker	USD $938
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $938
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	282
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $134,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	BUCK CONSULTANTS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	270
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $136,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

#2ALB607

Policy instance

Insurance contract or identification number	#2ALB607
Number of Individuals Covered	129
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	279
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-9881

Policy instance

Insurance contract or identification number	9906-9881
Number of Individuals Covered	349
Insurance policy start date	2012-04-01
Insurance policy end date	2013-04-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	24
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,692
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,956
Insurance broker name	WARREN C DER

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-9881

Policy instance

Insurance contract or identification number	9906-9881
Number of Individuals Covered	357
Insurance policy start date	2011-04-01
Insurance policy end date	2012-04-01
Total amount of commissions paid to insurance broker	USD $2,364
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,364
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	329
Insurance policy start date	2012-01-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $271,179
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

ME085

Policy instance

Insurance contract or identification number	ME085
Number of Individuals Covered	26
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,094
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,742
Insurance broker organization code?	3
Insurance broker name	WARREN C DER

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

#2ALB607

Policy instance

Insurance contract or identification number	#2ALB607
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 $1,220
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,220
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	287
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	298
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ABL961350

Policy instance

Insurance contract or identification number	ABL961350
Number of Individuals Covered	357
Insurance policy start date	2010-12-15
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $-1,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ESSEX DENTAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 43075 )

Policy contract number

5ALB607

Policy instance

Insurance contract or identification number	5ALB607
Number of Individuals Covered	283
Insurance policy start date	2011-01-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $424
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	308
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $-100
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTH PPO STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $233,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

000009798

Policy instance

Insurance contract or identification number	000009798
Number of Individuals Covered	311
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $92,617
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL LIFE, OPTIONAL DEP
Welfare Benefit Premiums Paid to Carrier	USD $3,421,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92,477
Insurance broker organization code?	3
Insurance broker name	GERALD CLARK C/O MERCER HEALTH

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

331957D

Policy instance

Insurance contract or identification number	331957D
Number of Individuals Covered	318
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $-8
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-32
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-8
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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

Policy contract number

ABL961350

Policy instance

Insurance contract or identification number	ABL961350
Number of Individuals Covered	306
Insurance policy start date	2009-12-15
Insurance policy end date	2010-12-15
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

866074G

Policy instance

Insurance contract or identification number	866074G
Number of Individuals Covered	291
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

ESSEX DENTAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 43075 )

Policy contract number

5ALB607

Policy instance

Insurance contract or identification number	5ALB607
Number of Individuals Covered	279
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $940
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $940
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

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Company Name:	ALBERICI GROUP INC.
Employer identification number (EIN):	431907310
NAIC Classification:	561110
NAIC Description:	Office Administrative Services