401k Plan data: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN plan

FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN
Plan identification number	001

FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

FRANK W. DIVER, INC. has sponsored the creation of one or more 401k plans.

Company Name: FRANK W. DIVER, INC.

Employer identification number (EIN): 510036860

NAIC Classification: 423100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2018-01-01 MARY JANE O'BRIEN
001 2017-01-01 MARY JANE O'BRIEN
001 2016-01-01 MARY JANE O'BRIEN
001 2015-01-01 MARY JANE O'BRIEN
001 2014-01-01 MARY JANE O'BRIEN
001 2013-01-01 MARY JANE O'BRIEN
001 2012-01-01 MARY JANE O'BRIEN 2013-05-21
001 2011-01-01 MARY JANE O'BRIEN 2012-06-07
001 2010-01-01 RICHARD L. DIVER 2011-05-20 RICHARD L. DIVER 2011-05-20

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2018-01-01	MARY JANE O'BRIEN
001	2017-01-01	MARY JANE O'BRIEN
001	2016-01-01	MARY JANE O'BRIEN
001	2015-01-01	MARY JANE O'BRIEN
001	2014-01-01	MARY JANE O'BRIEN
001	2013-01-01	MARY JANE O'BRIEN
001	2012-01-01	MARY JANE O'BRIEN	2013-05-21
001	2011-01-01	MARY JANE O'BRIEN	2012-06-07
001	2010-01-01	RICHARD L. DIVER	2011-05-20	RICHARD L. DIVER	2011-05-20

Plan Statistics for FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN

Measure Date Value
2018: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 68
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 77
Number of retired or separated participants receiving benefits 2018-01-01 1
Number of other retired or separated participants entitled to future benefits 2018-01-01 9
Total of all active and inactive participants 2018-01-01 87
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 87
Number of participants with account balances 2018-01-01 39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 1
2017: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 64
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 58
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 9
Total of all active and inactive participants 2017-01-01 68
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 68
Number of participants with account balances 2017-01-01 38
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 73
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 56
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 8
Total of all active and inactive participants 2016-01-01 64
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 64
Number of participants with account balances 2016-01-01 42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 3
2015: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 69
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 66
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 7
Total of all active and inactive participants 2015-01-01 73
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 73
Number of participants with account balances 2015-01-01 44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 3
2014: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 71
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 64
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 5
Total of all active and inactive participants 2014-01-01 69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 69
Number of participants with account balances 2014-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 63
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 66
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 5
Total of all active and inactive participants 2013-01-01 71
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 71
Number of participants with account balances 2013-01-01 47
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0

Measure	Date	Value
2018: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	68
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	77
Number of retired or separated participants receiving benefits	2018-01-01	1
Number of other retired or separated participants entitled to future benefits	2018-01-01	9
Total of all active and inactive participants	2018-01-01	87
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	87
Number of participants with account balances	2018-01-01	39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	1
2017: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	64
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	58
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	9
Total of all active and inactive participants	2017-01-01	68
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	68
Number of participants with account balances	2017-01-01	38
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	73
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	56
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	8
Total of all active and inactive participants	2016-01-01	64
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	64
Number of participants with account balances	2016-01-01	42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	3
2015: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	69
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	66
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	7
Total of all active and inactive participants	2015-01-01	73
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	73
Number of participants with account balances	2015-01-01	44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	3
2014: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	71
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	64
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	5
Total of all active and inactive participants	2014-01-01	69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	69
Number of participants with account balances	2014-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	63
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	66
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	5
Total of all active and inactive participants	2013-01-01	71
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	71
Number of participants with account balances	2013-01-01	47
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0

Financial Data on FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2018 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2018 401k financial data
Transfers to/from the plan	2018-12-31	$0
Total plan liabilities at end of year	2018-12-31	$0
Total plan liabilities at beginning of year	2018-12-31	$0
Total income from all sources	2018-12-31	$-70,698
Expenses. Total of all expenses incurred	2018-12-31	$274,748
Benefits paid (including direct rollovers)	2018-12-31	$271,771
Total plan assets at end of year	2018-12-31	$4,466,687
Total plan assets at beginning of year	2018-12-31	$4,812,133
Value of fidelity bond covering the plan	2018-12-31	$500,000
Total contributions received or receivable from participants	2018-12-31	$144,177
Expenses. Other expenses not covered elsewhere	2018-12-31	$0
Contributions received from other sources (not participants or employers)	2018-12-31	$0
Other income received	2018-12-31	$-274,133
Noncash contributions received	2018-12-31	$0
Net income (gross income less expenses)	2018-12-31	$-345,446
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$4,466,687
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$4,812,133
Total contributions received or receivable from employer(s)	2018-12-31	$59,258
Value of certain deemed distributions of participant loans	2018-12-31	$0
Value of corrective distributions	2018-12-31	$2,927
Expenses. Administrative service providers (salaries,fees and commissions)	2018-12-31	$50
2017 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2017 401k financial data
Transfers to/from the plan	2017-12-31	$0
Total plan liabilities at end of year	2017-12-31	$0
Total plan liabilities at beginning of year	2017-12-31	$0
Total income from all sources	2017-12-31	$846,061
Expenses. Total of all expenses incurred	2017-12-31	$286,564
Benefits paid (including direct rollovers)	2017-12-31	$278,979
Total plan assets at end of year	2017-12-31	$4,812,133
Total plan assets at beginning of year	2017-12-31	$4,252,636
Value of fidelity bond covering the plan	2017-12-31	$500,000
Assets. Value of tangible personal property	2017-12-31	$0
Total contributions received or receivable from participants	2017-12-31	$136,632
Assets. Value of loans (other than to participants)	2017-12-31	$0
Expenses. Other expenses not covered elsewhere	2017-12-31	$0
Contributions received from other sources (not participants or employers)	2017-12-31	$0
Other income received	2017-12-31	$661,057
Noncash contributions received	2017-12-31	$0
Net income (gross income less expenses)	2017-12-31	$559,497
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$4,812,133
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$4,252,636
Assets. Value of participant loans	2017-12-31	$0
Assets. Value of assets in partnership/joint-venture interests	2017-12-31	$0
Assets. Value of real-estate (other than employer real property)	2017-12-31	$0
Assets. Value of employer securities	2017-12-31	$0
Assets. Value of employer real property	2017-12-31	$0
Total contributions received or receivable from employer(s)	2017-12-31	$48,372
Value of certain deemed distributions of participant loans	2017-12-31	$0
Value of corrective distributions	2017-12-31	$7,535
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$50
2016 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2016 401k financial data
Transfers to/from the plan	2016-12-31	$0
Total plan liabilities at end of year	2016-12-31	$0
Total plan liabilities at beginning of year	2016-12-31	$0
Total income from all sources	2016-12-31	$548,304
Expenses. Total of all expenses incurred	2016-12-31	$204,715
Benefits paid (including direct rollovers)	2016-12-31	$191,994
Total plan assets at end of year	2016-12-31	$4,252,636
Total plan assets at beginning of year	2016-12-31	$3,909,047
Value of fidelity bond covering the plan	2016-12-31	$500,000
Total contributions received or receivable from participants	2016-12-31	$180,025
Expenses. Other expenses not covered elsewhere	2016-12-31	$0
Contributions received from other sources (not participants or employers)	2016-12-31	$34,867
Other income received	2016-12-31	$262,330
Noncash contributions received	2016-12-31	$0
Net income (gross income less expenses)	2016-12-31	$343,589
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$4,252,636
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$3,909,047
Total contributions received or receivable from employer(s)	2016-12-31	$71,082
Value of certain deemed distributions of participant loans	2016-12-31	$0
Value of corrective distributions	2016-12-31	$12,596
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$125
2015 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2015 401k financial data
Transfers to/from the plan	2015-12-31	$0
Total plan liabilities at end of year	2015-12-31	$0
Total plan liabilities at beginning of year	2015-12-31	$0
Total income from all sources	2015-12-31	$176,423
Expenses. Total of all expenses incurred	2015-12-31	$294,369
Benefits paid (including direct rollovers)	2015-12-31	$291,602
Total plan assets at end of year	2015-12-31	$3,909,047
Total plan assets at beginning of year	2015-12-31	$4,026,993
Value of fidelity bond covering the plan	2015-12-31	$500,000
Total contributions received or receivable from participants	2015-12-31	$159,549
Expenses. Other expenses not covered elsewhere	2015-12-31	$0
Contributions received from other sources (not participants or employers)	2015-12-31	$0
Other income received	2015-12-31	$-33,011
Noncash contributions received	2015-12-31	$0
Net income (gross income less expenses)	2015-12-31	$-117,946
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$3,909,047
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$4,026,993
Total contributions received or receivable from employer(s)	2015-12-31	$49,885
Value of certain deemed distributions of participant loans	2015-12-31	$0
Value of corrective distributions	2015-12-31	$2,642
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$125
2014 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total plan liabilities at end of year	2014-12-31	$0
Total plan liabilities at beginning of year	2014-12-31	$0
Total income from all sources	2014-12-31	$399,114
Expenses. Total of all expenses incurred	2014-12-31	$766,956
Benefits paid (including direct rollovers)	2014-12-31	$766,806
Total plan assets at end of year	2014-12-31	$4,026,993
Total plan assets at beginning of year	2014-12-31	$4,394,835
Value of fidelity bond covering the plan	2014-12-31	$500,000
Total contributions received or receivable from participants	2014-12-31	$144,821
Expenses. Other expenses not covered elsewhere	2014-12-31	$0
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$190,346
Noncash contributions received	2014-12-31	$0
Net income (gross income less expenses)	2014-12-31	$-367,842
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$4,026,993
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$4,394,835
Total contributions received or receivable from employer(s)	2014-12-31	$63,947
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$150
2013 : FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total plan liabilities at end of year	2013-12-31	$0
Total plan liabilities at beginning of year	2013-12-31	$0
Total income from all sources	2013-12-31	$813,497
Expenses. Total of all expenses incurred	2013-12-31	$43,102
Benefits paid (including direct rollovers)	2013-12-31	$43,052
Total plan assets at end of year	2013-12-31	$4,493,916
Total plan assets at beginning of year	2013-12-31	$3,723,521
Value of fidelity bond covering the plan	2013-12-31	$500,000
Total contributions received or receivable from participants	2013-12-31	$54,544
Expenses. Other expenses not covered elsewhere	2013-12-31	$0
Contributions received from other sources (not participants or employers)	2013-12-31	$114,401
Other income received	2013-12-31	$621,629
Noncash contributions received	2013-12-31	$0
Net income (gross income less expenses)	2013-12-31	$770,395
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$4,493,916
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$3,723,521
Total contributions received or receivable from employer(s)	2013-12-31	$22,923
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$50

Form 5500 Responses for FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN

2018: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: FRANK W. DIVER, INC. 401(K) PROFIT SHARING PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

331661-01

Policy instance

Insurance contract or identification number	331661-01
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-09-24
Total amount of commissions paid to insurance broker	USD $281
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $281
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELL FARGO ADV FIN NET M. KOTARSKI

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

331661-01

Policy instance

Insurance contract or identification number	331661-01
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 $617
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $617
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO ADVISORS FIN NETWORK LL

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Company Name:	FRANK W. DIVER, INC.
Employer identification number (EIN):	510036860
NAIC Classification:	423100