401k Plan data: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN plan

UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN
Plan identification number	501

UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

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

Company Name: UNIQUE FABRICATING, INC.

Employer identification number (EIN): 522108349

NAIC Classification: 325900
NAIC Description: Other Chemical Product and Preparation Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 THOMAS TEKIELE THOMAS TEKIELE 2019-07-25
501 2017-01-01 THOMAS TEKIELE THOMAS TEKIELE 2018-07-23
501 2016-01-01 THOMAS TEKIELE THOMAS TEKIELE 2017-07-27
501 2015-01-01 THOMAS TEKIELE THOMAS TEKIELE 2016-07-28
501 2014-01-01 THOMAS TEKIELE THOMAS TEKIELE 2015-07-28
501 2013-01-01 THOMAS TEKIELE THOMAS TEKIELE 2014-07-29
501 2012-01-01 THOMAS TEKIELE THOMAS TEKIELE 2013-06-26
501 2011-01-01 THOMAS TEKIELE THOMAS TEKIELE 2012-06-19
501 2010-01-01 THOMAS TEKIELE THOMAS TEKIELE 2011-07-25
501 2009-01-01 THOMAS TEKIELE THOMAS TEKIELE 2010-07-02

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2019-07-25
501	2017-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2018-07-23
501	2016-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2017-07-27
501	2015-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2016-07-28
501	2014-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2015-07-28
501	2013-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2014-07-29
501	2012-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2013-06-26
501	2011-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2012-06-19
501	2010-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2011-07-25
501	2009-01-01	THOMAS TEKIELE	THOMAS TEKIELE	2010-07-02

Plan Statistics for UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN

Measure Date Value
2022: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 489
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 280
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 280
2021: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 569
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 489
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 489
2020: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 654
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 569
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 569
2019: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 407
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 654
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 654
2018: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 549
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 407
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 407
2017: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 724
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 549
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 549
2016: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 373
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 724
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 0
Total of all active and inactive participants 2016-01-01 724
2015: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 449
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 373
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 373
2014: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 290
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 449
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 449
2013: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 290
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 0
Total of all active and inactive participants 2013-01-01 290
2012: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 251
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 293
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 293
2011: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 251
Total of all active and inactive participants 2011-01-01 251
2010: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 430
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 200
Total of all active and inactive participants 2010-01-01 200
2009: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 551
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 430
Total of all active and inactive participants 2009-01-01 430

Measure	Date	Value
2022: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	489
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	280
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	280
2021: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	569
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	489
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	489
2020: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	654
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	569
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	569
2019: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	407
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	654
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	654
2018: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	549
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	407
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	407
2017: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	724
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	549
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	549
2016: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	373
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	724
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	0
Total of all active and inactive participants	2016-01-01	724
2015: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	449
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	373
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	373
2014: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	290
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	449
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	449
2013: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	290
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	0
Total of all active and inactive participants	2013-01-01	290
2012: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	251
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	293
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	293
2011: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	251
Total of all active and inactive participants	2011-01-01	251
2010: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	430
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	200
Total of all active and inactive participants	2010-01-01	200
2009: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	551
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	430
Total of all active and inactive participants	2009-01-01	430

Form 5500 Responses for UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN

2022: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan is a collectively bargained plan	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan is a collectively bargained plan	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan is a collectively bargained plan	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan is a collectively bargained plan	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan is a collectively bargained plan	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan is a collectively bargained plan	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan is a collectively bargained plan	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan is a collectively bargained plan	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan is a collectively bargained plan	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan is a collectively bargained plan	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan is a collectively bargained plan	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan is a collectively bargained plan	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan is a collectively bargained plan	Yes
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: UNIQUE FABRICATING, INC. WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan is a collectively bargained plan	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

110964

Policy instance

Insurance contract or identification number	110964
Number of Individuals Covered	221
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,599
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,599
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

937074

Policy instance

Insurance contract or identification number	937074
Number of Individuals Covered	234
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $33,607
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, AD&D
Welfare Benefit Premiums Paid to Carrier	USD $299,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,607
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

110964

Policy instance

Insurance contract or identification number	110964
Number of Individuals Covered	466
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $13,945
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $283,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,945
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

937074

Policy instance

Insurance contract or identification number	937074
Number of Individuals Covered	254
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $36,695
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, AD&D
Welfare Benefit Premiums Paid to Carrier	USD $305,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,695
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

110964

Policy instance

Insurance contract or identification number	110964
Number of Individuals Covered	466
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,097
Total amount of fees paid to insurance company	USD $1,415
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $299,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,097
Insurance broker organization code?	3
Amount paid for insurance broker fees	1415

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	226
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $32,243
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, AD&D
Welfare Benefit Premiums Paid to Carrier	USD $251,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,243
Insurance broker organization code?	3

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

Policy contract number

LTD 126553

Policy instance

Insurance contract or identification number	LTD 126553
Number of Individuals Covered	133
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,281
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,281
Insurance broker organization code?	3

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

Policy contract number

XU251

Policy instance

Insurance contract or identification number	XU251
Number of Individuals Covered	131
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,083
Total amount of fees paid to insurance company	USD $988
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,083
Amount paid for insurance broker fees	988
Insurance broker organization code?	3

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

Policy contract number

VAR 206693

Policy instance

Insurance contract or identification number	VAR 206693
Number of Individuals Covered	206
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,036
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,036
Insurance broker organization code?	3

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

Policy contract number

VPS 326840

Policy instance

Insurance contract or identification number	VPS 326840
Number of Individuals Covered	114
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,016
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,016
Insurance broker organization code?	3

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

Policy contract number

VAR 206693

Policy instance

Insurance contract or identification number	VAR 206693
Number of Individuals Covered	235
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,176
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,176
Insurance broker organization code?	3

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

Policy contract number

GL 154621

Policy instance

Insurance contract or identification number	GL 154621
Number of Individuals Covered	218
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,112
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $56,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,112
Insurance broker organization code?	3

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

Policy contract number

VPL 301873

Policy instance

Insurance contract or identification number	VPL 301873
Number of Individuals Covered	33
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,057
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,057
Insurance broker organization code?	3

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

Policy contract number

VCI 800517

Policy instance

Insurance contract or identification number	VCI 800517
Number of Individuals Covered	5
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $717
Total amount of fees paid to insurance company	USD $4
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $7,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $717
Amount paid for insurance broker fees	4
Insurance broker organization code?	3

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

Policy contract number

VPS 326840

Policy instance

Insurance contract or identification number	VPS 326840
Number of Individuals Covered	114
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,853
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,853
Insurance broker organization code?	3

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

Policy contract number

LTD 126553

Policy instance

Insurance contract or identification number	LTD 126553
Number of Individuals Covered	152
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,339
Total amount of fees paid to insurance company	USD $45
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,339
Amount paid for insurance broker fees	45
Insurance broker organization code?	3

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

Policy contract number

VAI 825553

Policy instance

Insurance contract or identification number	VAI 825553
Number of Individuals Covered	67
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,525
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $15,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,525
Insurance broker organization code?	3

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

Policy contract number

XU251

Policy instance

Insurance contract or identification number	XU251
Number of Individuals Covered	135
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,916
Total amount of fees paid to insurance company	USD $1,157
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,916
Amount paid for insurance broker fees	1157
Insurance broker organization code?	3

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

Policy contract number

GL 154621

Policy instance

Insurance contract or identification number	GL 154621
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,153
Total amount of fees paid to insurance company	USD $1,328
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $60,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,153
Amount paid for insurance broker fees	1328
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

XU251

Policy instance

Insurance contract or identification number	XU251
Number of Individuals Covered	145
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,568
Total amount of fees paid to insurance company	USD $383
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,568
Amount paid for insurance broker fees	383
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED REPORT

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

Policy contract number

VAI 825553

Policy instance

Insurance contract or identification number	VAI 825553
Number of Individuals Covered	57
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,575
Total amount of fees paid to insurance company	USD $430
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $15,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,575
Amount paid for insurance broker fees	430
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

VPL 301873

Policy instance

Insurance contract or identification number	VPL 301873
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 $2,077
Total amount of fees paid to insurance company	USD $254
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,077
Amount paid for insurance broker fees	254
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

VPS 326840

Policy instance

Insurance contract or identification number	VPS 326840
Number of Individuals Covered	120
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,827
Total amount of fees paid to insurance company	USD $1,124
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,827
Amount paid for insurance broker fees	1124
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

VAR 206693

Policy instance

Insurance contract or identification number	VAR 206693
Number of Individuals Covered	217
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,212
Total amount of fees paid to insurance company	USD $196
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,212
Amount paid for insurance broker fees	196
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

LTD 126553

Policy instance

Insurance contract or identification number	LTD 126553
Number of Individuals Covered	133
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,516
Total amount of fees paid to insurance company	USD $540
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,516
Amount paid for insurance broker fees	540
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

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

Policy contract number

VCI 800517

Policy instance

Insurance contract or identification number	VCI 800517
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $934
Total amount of fees paid to insurance company	USD $127
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $934
Amount paid for insurance broker fees	127
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183823 00

Policy instance

Insurance contract or identification number	000010183823 00
Number of Individuals Covered	90
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,260
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $48,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,260
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183822 00

Policy instance

Insurance contract or identification number	000010183822 00
Number of Individuals Covered	116
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,624
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,624
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 17685

Policy instance

Insurance contract or identification number	400001000 17685
Number of Individuals Covered	136
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,957
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,957
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183821 00

Policy instance

Insurance contract or identification number	000010183821 00
Number of Individuals Covered	210
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $937
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $937
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	227
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,226
Total amount of fees paid to insurance company	USD $37,794
Welfare Benefit Premiums Paid to Carrier	USD $349,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,226
Amount paid for insurance broker fees	35775
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	226
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $33,308
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 $33,308
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00110964/0002

Policy instance

Insurance contract or identification number	00110964/0002
Number of Individuals Covered	276
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $792,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0008191

Policy instance

Insurance contract or identification number	0008191
Number of Individuals Covered	167
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,262
Dental 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 $1,262
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183821 00

Policy instance

Insurance contract or identification number	000010183821 00
Number of Individuals Covered	137
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $516
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $516
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183821 00

Policy instance

Insurance contract or identification number	000010183821 00
Number of Individuals Covered	18
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $178
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $178
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000 17

Policy instance

Insurance contract or identification number	000400001000 17
Number of Individuals Covered	58
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,427
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,427
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000 17

Policy instance

Insurance contract or identification number	000400001000 17
Number of Individuals Covered	56
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,329
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,329
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183821 00

Policy instance

Insurance contract or identification number	000010183821 00
Number of Individuals Covered	119
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $337
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $337
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010192168 00

Policy instance

Insurance contract or identification number	000010192168 00
Number of Individuals Covered	30
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $670
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $670
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183822 00

Policy instance

Insurance contract or identification number	000010183822 00
Number of Individuals Covered	81
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,239
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,239
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183822 00

Policy instance

Insurance contract or identification number	000010183822 00
Number of Individuals Covered	18
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $128
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $128
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183823 00

Policy instance

Insurance contract or identification number	000010183823 00
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 $1,198
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $7,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,198
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010183823 00

Policy instance

Insurance contract or identification number	000010183823 00
Number of Individuals Covered	37
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,809
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $12,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,809
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INSURANCE GRP

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0005303

Policy instance

Insurance contract or identification number	0005303
Number of Individuals Covered	339
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,114
Dental 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 $2,114
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK, INC

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0008191

Policy instance

Insurance contract or identification number	0008191
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,655
Dental 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 $232
Insurance broker organization code?	3
Insurance broker name	TIMOTHY ERNST

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00476755

Policy instance

Insurance contract or identification number	00476755
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 $2,330
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,330
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

50665

Policy instance

Insurance contract or identification number	50665
Number of Individuals Covered	225
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $858
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $562
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK INC

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00110964/0002

Policy instance

Insurance contract or identification number	00110964/0002
Number of Individuals Covered	250
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $29,264
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $713,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,264
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0005303

Policy instance

Insurance contract or identification number	0005303
Number of Individuals Covered	326
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,135
Dental 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 $2,645
Insurance broker organization code?	3
Insurance broker name	MEADOWBROOK, INC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	217
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $34,149
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 $34,149
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00476755

Policy instance

Insurance contract or identification number	00476755
Number of Individuals Covered	78
Insurance policy start date	2012-04-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,503
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0325902

Policy instance

Insurance contract or identification number	R0325902
Number of Individuals Covered	50
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,892
Total amount of fees paid to insurance company	USD $20
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	20
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $946
Insurance broker name	MALLIN, EVETT, SUSAN

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0008191-2001

Policy instance

Insurance contract or identification number	0008191-2001
Number of Individuals Covered	110
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

50665

Policy instance

Insurance contract or identification number	50665
Number of Individuals Covered	208
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $748
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $748
Insurance broker organization code?	3
Insurance broker name	TIMOTHY M ERNST

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000650J

Policy instance

Insurance contract or identification number	G000650J
Number of Individuals Covered	129
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $350
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $350
Insurance broker organization code?	3
Insurance broker name	TIMOTHY M ERNST

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0005303

Policy instance

Insurance contract or identification number	0005303
Number of Individuals Covered	301
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,674
Dental 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 $2,674
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	167
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $32,317
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 $32,317
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00110964/0002

Policy instance

Insurance contract or identification number	00110964/0002
Number of Individuals Covered	258
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $30,869
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $663,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,869
Insurance broker name	TIM ERNST

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000650J

Policy instance

Insurance contract or identification number	G000650J
Number of Individuals Covered	129
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $317
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0005303

Policy instance

Insurance contract or identification number	0005303
Number of Individuals Covered	276
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,666
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	135
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $32,909
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

001109640002

Policy instance

Insurance contract or identification number	001109640002
Number of Individuals Covered	276
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $30,706
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $647,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0008191-2001

Policy instance

Insurance contract or identification number	0008191-2001
Number of Individuals Covered	116
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

50665

Policy instance

Insurance contract or identification number	50665
Number of Individuals Covered	192
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $823
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL VISION ADMINISTRATORS, LLC (National Association of Insurance Commissioners NAIC id number: 11686 )

Policy contract number

50665

Policy instance

Insurance contract or identification number	50665
Number of Individuals Covered	191
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $731
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $731
Insurance broker organization code?	3
Insurance broker name	TIMOTHY M ERNST

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000650J

Policy instance

Insurance contract or identification number	G000650J
Number of Individuals Covered	131
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $325
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,254
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	TIMOTHY M ERNST

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

38074

Policy instance

Insurance contract or identification number	38074
Number of Individuals Covered	127
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $22,064
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 $22,064
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

001109640002

Policy instance

Insurance contract or identification number	001109640002
Number of Individuals Covered	265
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $35,376
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $812,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,376
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0005303

Policy instance

Insurance contract or identification number	0005303
Number of Individuals Covered	245
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,818
Dental 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 $2,818
Insurance broker organization code?	3
Insurance broker name	TIM ERNST

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0008191-2001

Policy instance

Insurance contract or identification number	0008191-2001
Number of Individuals Covered	149
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	UNIQUE FABRICATING, INC.
Employer identification number (EIN):	522108349
NAIC Classification:	325900
NAIC Description:	Other Chemical Product and Preparation Manufacturing