401k Plan data: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN plan

J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	J.W.W. ENTERPRISES HEALTH BENEFIT PLAN
Plan identification number	501

J.W.W. ENTERPRISES HEALTH BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental

401k Sponsoring company profile

JWW ENTERPRISES & ASSOCIATES, INC has sponsored the creation of one or more 401k plans.

Company Name: JWW ENTERPRISES & ASSOCIATES, INC

Employer identification number (EIN): 521305529

NAIC Classification: 238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan J.W.W. ENTERPRISES HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JAMES W. WILCOXON
501 2011-01-01 JAMES W. WILCOXON
501 2010-01-01 JAMES W. WILCOXON
501 2009-01-01 JAMES W. WILCOXON

Plan Statistics for J.W.W. ENTERPRISES HEALTH BENEFIT PLAN

401k plan membership statisitcs for J.W.W. ENTERPRISES HEALTH BENEFIT PLAN

Measure Date Value
2017: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 185
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 49
Total of all active and inactive participants 2017-01-01 49
2016: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 185
Total of all active and inactive participants 2016-01-01 185
2015: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 188
Total of all active and inactive participants 2015-01-01 188
2014: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 201
Total of all active and inactive participants 2014-01-01 201
2013: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 208
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 200
Total of all active and inactive participants 2013-01-01 200
2012: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 208
Total of all active and inactive participants 2012-01-01 208
2011: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 148
Total of all active and inactive participants 2011-01-01 148
2010: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 147
Total of all active and inactive participants 2010-01-01 147
2009: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 154
Total of all active and inactive participants 2009-01-01 154

Measure	Date	Value
2017: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	185
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	49
Total of all active and inactive participants	2017-01-01	49
2016: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	185
Total of all active and inactive participants	2016-01-01	185
2015: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	188
Total of all active and inactive participants	2015-01-01	188
2014: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	201
Total of all active and inactive participants	2014-01-01	201
2013: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	208
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	200
Total of all active and inactive participants	2013-01-01	200
2012: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	208
Total of all active and inactive participants	2012-01-01	208
2011: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	148
Total of all active and inactive participants	2011-01-01	148
2010: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	147
Total of all active and inactive participants	2010-01-01	147
2009: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	154
Total of all active and inactive participants	2009-01-01	154

Form 5500 Responses for J.W.W. ENTERPRISES HEALTH BENEFIT PLAN

2017: J.W.W. ENTERPRISES HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2015: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2014: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2013: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2012: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2011: J.W.W. ENTERPRISES HEALTH 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 benefit arrangement – Insurance	Yes
2010: J.W.W. ENTERPRISES HEALTH BENEFIT 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 benefit arrangement – Insurance	Yes
2009: J.W.W. ENTERPRISES HEALTH BENEFIT 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	49
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $459
Total amount of fees paid to insurance company	USD $305
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,053
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 organization code?	3
Amount paid for insurance broker fees	305
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	KAREN R. HAMMOND

DOMINIONNATIONAL DENTAL (National Association of Insurance Commissioners NAIC id number: 95657 )

Policy contract number

177896

Policy instance

Insurance contract or identification number	177896
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $387
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $223
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS CORP. OF AMERICA

DOMINIONNATIONAL DENTAL (National Association of Insurance Commissioners NAIC id number: 95657 )

Policy contract number

177898

Policy instance

Insurance contract or identification number	177898
Number of Individuals Covered	3
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $150
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	EMPLOYEE BENEFITS CORP. OF AMERICA

DOMINIONNATIONAL DENTAL (National Association of Insurance Commissioners NAIC id number: 95657 )

Policy contract number

177894

Policy instance

Insurance contract or identification number	177894
Number of Individuals Covered	5
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $139
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS CORP. OF AMERICA

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1K45

Policy instance

Insurance contract or identification number	1K45
Number of Individuals Covered	33
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,320
Total amount of fees paid to insurance company	USD $2,807
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $402,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,342
Amount paid for insurance broker fees	18
Additional information about fees paid to insurance broker	NON-MONETARY INCENTIVE
Insurance broker organization code?	3
Insurance broker name	ALAN J. ZUCCARI INC.

DOMINIONNATIONAL DENTAL (National Association of Insurance Commissioners NAIC id number: 95657 )

Policy contract number

177900

Policy instance

Insurance contract or identification number	177900
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS CORP. OF AMERICA

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
Number of Individuals Covered	3
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $180
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
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	22
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $371
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $371
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	184
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,400
Total amount of fees paid to insurance company	USD $970
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,400
Insurance broker organization code?	3
Amount paid for insurance broker fees	970
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NCIA INSURANCE AGENCY

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	43
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $83
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	10
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $114
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	29
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $435
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $435
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
Number of Individuals Covered	14
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $31
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1K45

Policy instance

Insurance contract or identification number	1K45
Number of Individuals Covered	74
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $17,117
Total amount of fees paid to insurance company	USD $171
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $765,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,117
Amount paid for insurance broker fees	34
Additional information about fees paid to insurance broker	NON-MONETARY INCENTIVE
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFITS CORP. OF AMERICA

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1K45

Policy instance

Insurance contract or identification number	1K45
Number of Individuals Covered	74
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,726
Total amount of fees paid to insurance company	USD $43
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 $736,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,726
Amount paid for insurance broker fees	43
Additional information about fees paid to insurance broker	NON-MONETARY INCENTIVE
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	197
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,474
Total amount of fees paid to insurance company	USD $1,007
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 $11,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,474
Insurance broker organization code?	3
Amount paid for insurance broker fees	1007
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NCIA INSURANCE AGENCY

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	33
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $380
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 $5,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $380
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	25
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $367
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 $5,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $367
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
Number of Individuals Covered	5
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $16
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 $225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	45
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $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 $1,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $52
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 $750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	10
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $153
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 $2,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1K45

Policy instance

Insurance contract or identification number	1K45
Number of Individuals Covered	74
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $21,248
Total amount of fees paid to insurance company	USD $46
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 $630,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,248
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	NON-MONETARY INCENTIVE
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	26
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $297
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 $4,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $297
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	20
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $232
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 $3,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $232
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	197
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,267
Total amount of fees paid to insurance company	USD $867
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 $9,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,267
Insurance broker organization code?	3
Amount paid for insurance broker fees	867
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NCIA INSURANCE AGENCY

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
Number of Individuals Covered	26
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $65
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 $925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	53
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $118
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 $1,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
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 $13
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 $180
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
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	11
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $151
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 $2,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $151
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	23
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $260
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 $3,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $260
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

4721030000

Policy instance

Insurance contract or identification number	4721030000
Number of Individuals Covered	8
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $932
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 $31,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $932
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	15
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $215
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 $2,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $215
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	14
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $165
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 $2,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $165
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	203
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,399
Total amount of fees paid to insurance company	USD $935
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 $9,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,399
Insurance broker organization code?	3
Amount paid for insurance broker fees	935
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NCIA INSURANCE AGENCY

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
Number of Individuals Covered	25
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $69
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 $915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	53
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $130
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 $1,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

COVENTRY HEALTH CARE OF DELAWARE (National Association of Insurance Commissioners NAIC id number: 96460 )

Policy contract number

4721030000

Policy instance

Insurance contract or identification number	4721030000
Number of Individuals Covered	124
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $15,165
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 $500,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,165
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1K45

Policy instance

Insurance contract or identification number	1K45
Number of Individuals Covered	77
Insurance policy start date	2012-11-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,257
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 $106,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,257
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
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 $14
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 $180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	12
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $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 $2,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

4721030000

Policy instance

Insurance contract or identification number	4721030000
Number of Individuals Covered	137
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $22,275
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 $622,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	12
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	15
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $148
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 $2,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	141
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,094
Total amount of fees paid to insurance company	USD $731
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 $7,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
Number of Individuals Covered	37
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $76
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 $1,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	69
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $127
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 $1,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
Number of Individuals Covered	3
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11
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 $180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8001

Policy instance

Insurance contract or identification number	023526-8001
Number of Individuals Covered	6
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $20
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 $280
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
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8002

Policy instance

Insurance contract or identification number	023526-8002
Number of Individuals Covered	86
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $181
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 $2,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $181
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-8003

Policy instance

Insurance contract or identification number	023526-8003
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 $98
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 $1,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $98
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 )

Policy contract number

OM2V

Policy instance

Insurance contract or identification number	OM2V
Number of Individuals Covered	72
Insurance policy start date	2010-01-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $11,960
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 $521,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,960
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

MFDOM2V01X

Policy instance

Insurance contract or identification number	MFDOM2V01X
Number of Individuals Covered	147
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,109
Total amount of fees paid to insurance company	USD $742
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 $7,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,109
Insurance broker organization code?	3
Amount paid for insurance broker fees	742
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NCIA INSURANCE AGENCY

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4301

Policy instance

Insurance contract or identification number	023526-4301
Number of Individuals Covered	16
Insurance policy start date	2010-06-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $82
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 $1,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4303

Policy instance

Insurance contract or identification number	023526-4303
Number of Individuals Covered	10
Insurance policy start date	2010-06-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $55
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 $908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

COVENTRY HEALTH CARE OF DELAWARE (National Association of Insurance Commissioners NAIC id number: 96460 )

Policy contract number

4721030000

Policy instance

Insurance contract or identification number	4721030000
Number of Individuals Covered	143
Insurance policy start date	2010-10-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,334
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 $155,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,334
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

DENTAQUEST MID-ATLANTIC, INC. (National Association of Insurance Commissioners NAIC id number: 52040 )

Policy contract number

023526-4302

Policy instance

Insurance contract or identification number	023526-4302
Number of Individuals Covered	8
Insurance policy start date	2010-06-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53
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 $844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53
Insurance broker organization code?	3
Insurance broker name	COLIN B. ROMINE

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Company Name:	JWW ENTERPRISES & ASSOCIATES, INC
Employer identification number (EIN):	521305529
NAIC Classification:	238900