401k Plan data: DAKOTA KING FLEXIBLE SPENDING PLAN plan

DAKOTA KING FLEXIBLE SPENDING PLAN 401k Plan overview

Plan Name	DAKOTA KING FLEXIBLE SPENDING PLAN
Plan identification number	501

DAKOTA KING FLEXIBLE SPENDING PLAN Benefits

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

401k Sponsoring company profile

DAKOTA KING INC has sponsored the creation of one or more 401k plans.

Company Name: DAKOTA KING INC

Employer identification number (EIN): 460388700

NAIC Classification: 722300
NAIC Description: Special Food Services

Additional information about DAKOTA KING INC

Jurisdiction of Incorporation: South Dakota Secretary of State

Incorporation Date:

Company Identification Number: DB024021

More information about DAKOTA KING INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DAKOTA KING FLEXIBLE SPENDING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 TERRY SCHNEPF
501 2011-01-01 TERRY SCHNEPF
501 2010-01-01 TERRY SCHNEPF
501 2009-01-01 TERRY SCHNEPF

Plan Statistics for DAKOTA KING FLEXIBLE SPENDING PLAN

401k plan membership statisitcs for DAKOTA KING FLEXIBLE SPENDING PLAN

Measure Date Value
2016: DAKOTA KING FLEXIBLE SPENDING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 233
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: DAKOTA KING FLEXIBLE SPENDING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 202
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 233
Total of all active and inactive participants 2015-01-01 233
2014: DAKOTA KING FLEXIBLE SPENDING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 202
Total of all active and inactive participants 2014-01-01 202
2013: DAKOTA KING FLEXIBLE SPENDING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 175
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 171
Total of all active and inactive participants 2013-01-01 171
2012: DAKOTA KING FLEXIBLE SPENDING PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 175
Total of all active and inactive participants 2012-01-01 175
2011: DAKOTA KING FLEXIBLE SPENDING PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 154
Total of all active and inactive participants 2011-01-01 154
2010: DAKOTA KING FLEXIBLE SPENDING PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 169
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 170
Total of all active and inactive participants 2010-01-01 170
2009: DAKOTA KING FLEXIBLE SPENDING PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 143
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 169
Total of all active and inactive participants 2009-01-01 169

Measure	Date	Value
2016: DAKOTA KING FLEXIBLE SPENDING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	233
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: DAKOTA KING FLEXIBLE SPENDING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	202
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	233
Total of all active and inactive participants	2015-01-01	233
2014: DAKOTA KING FLEXIBLE SPENDING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	202
Total of all active and inactive participants	2014-01-01	202
2013: DAKOTA KING FLEXIBLE SPENDING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	175
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	171
Total of all active and inactive participants	2013-01-01	171
2012: DAKOTA KING FLEXIBLE SPENDING PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	175
Total of all active and inactive participants	2012-01-01	175
2011: DAKOTA KING FLEXIBLE SPENDING PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	154
Total of all active and inactive participants	2011-01-01	154
2010: DAKOTA KING FLEXIBLE SPENDING PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	169
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	170
Total of all active and inactive participants	2010-01-01	170
2009: DAKOTA KING FLEXIBLE SPENDING PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	169
Total of all active and inactive participants	2009-01-01	169

Form 5500 Responses for DAKOTA KING FLEXIBLE SPENDING PLAN

2016: DAKOTA KING FLEXIBLE SPENDING PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Mulitple employer plan
2016-01-01	This submission is the final filing	Yes
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: DAKOTA KING FLEXIBLE SPENDING PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Mulitple 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: DAKOTA KING FLEXIBLE SPENDING PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Mulitple 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: DAKOTA KING FLEXIBLE SPENDING PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Mulitple 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: DAKOTA KING FLEXIBLE SPENDING 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: DAKOTA KING FLEXIBLE SPENDING 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
2010: DAKOTA KING FLEXIBLE SPENDING PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: DAKOTA KING FLEXIBLE SPENDING PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	269
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,517
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,517
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	34
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $106
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $106
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	17
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $679
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $679
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	217
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,259
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,694
Insurance broker organization code?	3
Insurance broker name	THOMAS MAYER

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	88
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $274
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $274
Insurance broker organization code?	3
Insurance broker name	WILLIAM MCGREEVY

DAKOTACARE (National Association of Insurance Commissioners NAIC id number: 96598 )

Policy contract number

DD14209

Policy instance

Insurance contract or identification number	DD14209
Number of Individuals Covered	223
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $26,982
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,982
Insurance broker organization code?	3
Insurance broker name	LISA MAKA

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	5
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $88
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88
Insurance broker organization code?	3
Insurance broker name	AFLAC REPRESENTATIVES

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040142

Policy instance

Insurance contract or identification number	HP040142
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $2,230
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,230
Insurance broker organization code?	3
Insurance broker name	MISSOURI VALLEY INSURANCE

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

Policy contract number

103444

Policy instance

Insurance contract or identification number	103444
Number of Individuals Covered	51
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,548
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,548
Insurance broker name	WILLIAMS INSURANCE AGENCY

AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 )

Policy contract number

SD429

Policy instance

Insurance contract or identification number	SD429
Number of Individuals Covered	199
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $21,474
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,474
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,085
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 $20,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,564
Insurance broker organization code?	3
Insurance broker name	THOMAS MAYER

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	65
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $209
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Insurance broker organization code?	3
Insurance broker name	WILLIAM MCGREEVY

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	19
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $781
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 $8,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $382
Insurance broker organization code?	3
Insurance broker name	RENAE SALLQUIST KNOPF

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	2
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $111
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 $829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46
Insurance broker organization code?	3
Insurance broker name	CYNTHIA WELKEN-PLACE

SANFORD HEALTH PLAN OF MN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040142

Policy instance

Insurance contract or identification number	HP040142
Number of Individuals Covered	16
Insurance policy start date	2014-08-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,757
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 $53,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,757
Insurance broker organization code?	3
Insurance broker name	MISSOURI VALLEY INSURANCE

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	35
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $120
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $120
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	287
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,425
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,425
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

SANFORD HEALTH PLAN OF MN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040142

Policy instance

Insurance contract or identification number	HP040142
Number of Individuals Covered	7
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,058
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 $20,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,058
Insurance broker organization code?	3
Insurance broker name	MISSOURI VALLEY INSURANCE

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $269
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 $2,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78
Insurance broker organization code?	3
Insurance broker name	KATE PALCZEWSKI

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	19
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,194
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 $10,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $632
Insurance broker organization code?	3
Insurance broker name	MICHAEL TOMLINSON

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	54
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $187
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $187
Insurance broker organization code?	3
Insurance broker name	WILLIAM MCGREEVY

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	206
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,808
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 $18,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,356
Insurance broker organization code?	3
Insurance broker name	THOMAS MAYER

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	271
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,105
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,105
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 )

Policy contract number

SD429

Policy instance

Insurance contract or identification number	SD429
Number of Individuals Covered	154
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,086
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,086
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	35
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	21
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $999
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 $11,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $999
Insurance broker name	WILLIAMS INSURANCE AGENCY

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	274
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,106
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,106
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	213
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,840
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 $18,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,380
Insurance broker organization code?	3
Insurance broker name	THOMAS MAYER

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	57
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $135
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $135
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	61
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $226
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $226
Insurance broker organization code?	3
Insurance broker name	WILLIAM MCGREEVY

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $493
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 $4,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $156
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CSP INSURANCE AGENT INC

AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 )

Policy contract number

SD429

Policy instance

Insurance contract or identification number	SD429
Number of Individuals Covered	173
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $19,369
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,369
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	22
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,182
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 $13,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	80
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $292
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	43
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $143
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	209
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,804
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 $18,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	297
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,124
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 )

Policy contract number

SD429

Policy instance

Insurance contract or identification number	SD429
Number of Individuals Covered	189
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $20,749
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	5
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $596
Total amount of fees paid to insurance company	USD $60
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 $5,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ANM50

Policy instance

Insurance contract or identification number	ANM50
Number of Individuals Covered	8
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,555
Total amount of fees paid to insurance company	USD $109
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 $7,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $563
Amount paid for insurance broker fees	42
Insurance broker organization code?	3
Insurance broker name	NANCY FENNERN

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

77536

Policy instance

Insurance contract or identification number	77536
Number of Individuals Covered	28
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,071
Total amount of fees paid to insurance company	USD $296
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 $16,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,071
Amount paid for insurance broker fees	296
Insurance broker name	WILLIAMS INSURANCE AGENCY

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

Policy contract number

GL 132331

Policy instance

Insurance contract or identification number	GL 132331
Number of Individuals Covered	92
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $325
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $325
Insurance broker organization code?	3
Insurance broker name	WILLIAM MCGREEVY

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030845

Policy instance

Insurance contract or identification number	010-030845
Number of Individuals Covered	231
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,740
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 $17,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,305
Insurance broker organization code?	3
Insurance broker name	THOMAS MAYER

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2177

Policy instance

Insurance contract or identification number	2177
Number of Individuals Covered	305
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,122
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 )

Policy contract number

SD429

Policy instance

Insurance contract or identification number	SD429
Number of Individuals Covered	215
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $20,161
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,161
Insurance broker organization code?	3
Insurance broker name	TIM DONOHUE

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

Policy contract number

GL 126455

Policy instance

Insurance contract or identification number	GL 126455
Number of Individuals Covered	44
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $142
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $142
Insurance broker organization code?	3
Insurance broker name	WILLIAMS INSURANCE AGENCY

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Company Name:	DAKOTA KING INC
Employer identification number (EIN):	460388700
NAIC Classification:	722300
NAIC Description:	Special Food Services

Jurisdiction of Incorporation:	South Dakota Secretary of State
Incorporation Date:
Company Identification Number:	DB024021