401k Plan data: FUNDER AMERICA INC WELFARE BENEFIT PLAN plan

FUNDER AMERICA INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	FUNDER AMERICA INC WELFARE BENEFIT PLAN
Plan identification number	502

FUNDER AMERICA INC WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

FUNDER AMERICA INC has sponsored the creation of one or more 401k plans.

Company Name: FUNDER AMERICA INC

Employer identification number (EIN): 561025069

NAIC Classification: 337000

Additional information about FUNDER AMERICA INC

Jurisdiction of Incorporation: North Carolina Secretary of State

Incorporation Date:

Company Identification Number: 0056497

More information about FUNDER AMERICA INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FUNDER AMERICA INC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-07-01
502 2020-07-01
502 2019-07-01
502 2018-07-01
502 2017-07-01 MARSHA LAWS
502 2016-07-01 MARSHA LAWS
502 2015-07-01 MARSHA LAWS
502 2014-07-01 MARSHA LAWS
502 2013-07-01 MARSHA LAWS
502 2012-07-01 MARSHA LAWS
502 2011-07-01 MARSHA LAWS

Plan Statistics for FUNDER AMERICA INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for FUNDER AMERICA INC WELFARE BENEFIT PLAN

Measure Date Value
2021: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 14
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 13
Total of all active and inactive participants 2021-07-01 13
2020: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 182
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 14
Total of all active and inactive participants 2020-07-01 14
2019: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 217
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 182
Total of all active and inactive participants 2019-07-01 182
2018: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 236
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 217
Total of all active and inactive participants 2018-07-01 217
2017: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 211
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 236
Total of all active and inactive participants 2017-07-01 236
2016: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 229
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 211
Total of all active and inactive participants 2016-07-01 211
2015: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 226
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 229
Total of all active and inactive participants 2015-07-01 229
2014: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 215
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 226
Total of all active and inactive participants 2014-07-01 226
2013: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 223
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 215
Total of all active and inactive participants 2013-07-01 215
2012: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 175
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 223
Total of all active and inactive participants 2012-07-01 223
2011: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 159
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 175
Total of all active and inactive participants 2011-07-01 175

Measure	Date	Value
2021: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	14
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	13
Total of all active and inactive participants	2021-07-01	13
2020: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	182
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	14
Total of all active and inactive participants	2020-07-01	14
2019: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	217
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	182
Total of all active and inactive participants	2019-07-01	182
2018: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	236
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	217
Total of all active and inactive participants	2018-07-01	217
2017: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	211
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	236
Total of all active and inactive participants	2017-07-01	236
2016: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	229
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	211
Total of all active and inactive participants	2016-07-01	211
2015: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	226
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	229
Total of all active and inactive participants	2015-07-01	229
2014: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	215
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	226
Total of all active and inactive participants	2014-07-01	226
2013: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	223
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	215
Total of all active and inactive participants	2013-07-01	215
2012: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	175
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	223
Total of all active and inactive participants	2012-07-01	223
2011: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	159
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	175
Total of all active and inactive participants	2011-07-01	175

Form 5500 Responses for FUNDER AMERICA INC WELFARE BENEFIT PLAN

2021: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: FUNDER AMERICA INC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4841011

Policy instance

Insurance contract or identification number	E4841011
Number of Individuals Covered	13
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,614
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $19,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $578
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

31068

Policy instance

Insurance contract or identification number	31068
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4841011

Policy instance

Insurance contract or identification number	E4841011
Number of Individuals Covered	14
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,888
Total amount of fees paid to insurance company	USD $22
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $20,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Amount paid for insurance broker fees	4
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

082478

Policy instance

Insurance contract or identification number	082478
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	95
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,054
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $7,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $354
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

31068

Policy instance

Insurance contract or identification number	31068
Number of Individuals Covered	69
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,004
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,004
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	95
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $3,997
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,342
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	45
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,165
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $390
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	27
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $228
Total amount of fees paid to insurance company	USD $9
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	41
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,819
Total amount of fees paid to insurance company	USD $43
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,128
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4841011

Policy instance

Insurance contract or identification number	E4841011
Number of Individuals Covered	19
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $3,751
Total amount of fees paid to insurance company	USD $368
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $24,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,470
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

082478

Policy instance

Insurance contract or identification number	082478
Number of Individuals Covered	182
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $53,368
Total amount of fees paid to insurance company	USD $301
Health Insurance Welfare Benefit	Yes
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 $53,368
Amount paid for insurance broker fees	301
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4841011

Policy instance

Insurance contract or identification number	E4841011
Number of Individuals Covered	19
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $4,110
Total amount of fees paid to insurance company	USD $424
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $24,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,332
Amount paid for insurance broker fees	266
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	58
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $3,657
Total amount of fees paid to insurance company	USD $328
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
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 $2,194
Amount paid for insurance broker fees	328
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	34
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $313
Total amount of fees paid to insurance company	USD $30
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $188
Amount paid for insurance broker fees	30
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	102
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $4,186
Total amount of fees paid to insurance company	USD $578
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,791
Amount paid for insurance broker fees	578
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	47
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,304
Total amount of fees paid to insurance company	USD $181
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $869
Amount paid for insurance broker fees	181
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	102
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,116
Total amount of fees paid to insurance company	USD $154
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $7,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $744
Amount paid for insurance broker fees	154
Additional information about fees paid to insurance broker	FEES PAID/ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

31068

Policy instance

Insurance contract or identification number	31068
Number of Individuals Covered	67
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,086
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,086
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

082478

Policy instance

Insurance contract or identification number	082478
Number of Individuals Covered	217
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $56,118
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
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 $56,118
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4841011

Policy instance

Insurance contract or identification number	E4841011
Number of Individuals Covered	26
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $16,681
Total amount of fees paid to insurance company	USD $3,774
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $28,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1D034692

Policy instance

Insurance contract or identification number	1D034692
Number of Individuals Covered	103
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $7,235
Total amount of fees paid to insurance company	USD $2,783
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	104
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,195
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $7,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

31068

Policy instance

Insurance contract or identification number	31068
Number of Individuals Covered	147
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $966
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	52
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,310
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	104
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $4,233
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	38
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $330
Total amount of fees paid to insurance company	USD $7
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	65
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,600
Total amount of fees paid to insurance company	USD $37
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $14,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

911541

Policy instance

Insurance contract or identification number	911541
Number of Individuals Covered	236
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $22,801
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	83
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $4,282
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,569
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

K4468

Policy instance

Insurance contract or identification number	K4468
Number of Individuals Covered	55
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $8,038
Total amount of fees paid to insurance company	USD $160
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $39,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,825
Amount paid for insurance broker fees	3
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DWAYNE GOLDWYN SIMPSON

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	43
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $423
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEM
Welfare Benefit Premiums Paid to Carrier	USD $1,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	111
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $3,438
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,292
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	67
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,442
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $961
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	111
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,226
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $8,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $817
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

28372

Policy instance

Insurance contract or identification number	28372
Number of Individuals Covered	122
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,030
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,030
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

076372

Policy instance

Insurance contract or identification number	076372
Number of Individuals Covered	229
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $51,385
Total amount of fees paid to insurance company	USD $1,000
Health Insurance Welfare Benefit	Yes
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 $51,385
Amount paid for insurance broker fees	1000
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	LISA L. HAMLETT

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

Policy contract number

K4468

Policy instance

Insurance contract or identification number	K4468
Number of Individuals Covered	59
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,769
Total amount of fees paid to insurance company	USD $208
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $27,783
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
Amount paid for insurance broker fees	33
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DWAYNE GOLDWYN SIMPSON

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	88
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $4,368
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,621
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

28372

Policy instance

Insurance contract or identification number	28372
Number of Individuals Covered	117
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $980
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $980
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	108
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,308
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,205
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	108
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,171
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $7,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $781
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	64
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,428
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $952
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	44
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $489
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEM
Welfare Benefit Premiums Paid to Carrier	USD $1,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $293
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

076372

Policy instance

Insurance contract or identification number	076372
Number of Individuals Covered	226
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $40,770
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
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 $40,770
Insurance broker organization code?	3
Insurance broker name	LISA L. HAMLETT

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	88
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,980
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $15,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,388
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	45
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $500
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEM
Welfare Benefit Premiums Paid to Carrier	USD $1,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $300
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

Policy instance

Number of Individuals Covered	48
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,440
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SUPPLEMENTAL HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $34,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,127
Insurance broker organization code?	3
Insurance broker name	DWAYNE GOLDWYN SIMPSON

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	100
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,991
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,994
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	100
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,458
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $972
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

31068

Policy instance

Insurance contract or identification number	31068
Number of Individuals Covered	109
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $859
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $859
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

076372

Policy instance

Insurance contract or identification number	076372
Number of Individuals Covered	215
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $42,651
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $758,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,651
Insurance broker organization code?	3
Insurance broker name	LISA L. HAMLETT

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	64
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,381
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $921
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

20104/V76372

Policy instance

Insurance contract or identification number	20104/V76372
Number of Individuals Covered	109
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,351
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,351
Insurance broker organization code?	3
Insurance broker name	LISA HAMLETT

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	103
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,527
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $10,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,018
Insurance broker organization code?	3
Insurance broker name	SAEGIS BENEFITS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	70
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,475
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $983
Insurance broker organization code?	3
Insurance broker name	SAEGIS BENEFITS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	103
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,162
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,108
Insurance broker organization code?	3
Insurance broker name	SAEGIS BENEFITS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	91
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,312
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,587
Insurance broker organization code?	3
Insurance broker name	SAEGIS BENEFITS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50012132

Policy instance

Insurance contract or identification number	50012132
Number of Individuals Covered	45
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $512
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEM
Welfare Benefit Premiums Paid to Carrier	USD $2,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $307
Insurance broker organization code?	3
Insurance broker name	SAEGIS BENEFITS

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

076372

Policy instance

Insurance contract or identification number	076372
Number of Individuals Covered	223
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $46,400
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $698,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,400
Insurance broker organization code?	3
Insurance broker name	LISA L. HAMLETT

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

533696

Policy instance

Insurance contract or identification number	533696
Number of Individuals Covered	175
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $35,343
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 $589,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	113
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $4,818
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

038-1630-00

Policy instance

Insurance contract or identification number	038-1630-00
Number of Individuals Covered	113
Insurance policy start date	2011-07-01
Insurance policy end date	2012-07-01
Total amount of commissions paid to insurance broker	USD $7,969
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 $57,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	113
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,315
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

28372

Policy instance

Insurance contract or identification number	28372
Number of Individuals Covered	105
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,125
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	60
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,137
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

533696

Policy instance

Insurance contract or identification number	533696
Number of Individuals Covered	159
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $33,975
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 $566,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

28372

Policy instance

Insurance contract or identification number	28372
Number of Individuals Covered	96
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,063
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	106
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,805
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

038-1630-00

Policy instance

Insurance contract or identification number	038-1630-00
Number of Individuals Covered	109
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,464
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 $52,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	105
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $2,801
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010481

Policy instance

Insurance contract or identification number	010481
Number of Individuals Covered	54
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,004
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	FUNDER AMERICA INC
Employer identification number (EIN):	561025069
NAIC Classification:	337000

Jurisdiction of Incorporation:	North Carolina Secretary of State
Incorporation Date:
Company Identification Number:	0056497