401k Plan data: APEX ARIDYNE CORP WELFARE PLAN plan

APEX ARIDYNE CORP WELFARE PLAN 401k Plan overview

Plan Name	APEX ARIDYNE CORP WELFARE PLAN
Plan identification number	510

APEX ARIDYNE CORP WELFARE PLAN Benefits

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

401k Sponsoring company profile

APEX ARIDYNE CORP. has sponsored the creation of one or more 401k plans.

Company Name: APEX ARIDYNE CORP.

Employer identification number (EIN): 561163708

NAIC Classification: 313000
NAIC Description: Textile Mills

Form 5500 Filing Information

Submission information for form 5500 for 401k plan APEX ARIDYNE CORP WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
510 2022-06-01 PATRICK GILLEN 2023-03-14 PATRICK GILLEN 2023-03-14
510 2020-06-01 DAVID KURZ 2022-01-11 DAVID KURZ 2022-01-11
510 2019-06-01 DAVID KURZ 2020-12-22
510 2018-06-01 DAVID KURZ 2020-01-15
510 2017-06-01 DAVID KURZ
510 2016-06-01 DAVID KURZ
510 2016-06-01 DAVID KURZ

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2022-06-01	PATRICK GILLEN	2023-03-14	PATRICK GILLEN	2023-03-14
510	2020-06-01	DAVID KURZ	2022-01-11	DAVID KURZ	2022-01-11
510	2019-06-01	DAVID KURZ	2020-12-22
510	2018-06-01	DAVID KURZ	2020-01-15
510	2017-06-01	DAVID KURZ
510	2016-06-01	DAVID KURZ
510	2016-06-01			DAVID KURZ

Plan Statistics for APEX ARIDYNE CORP WELFARE PLAN

401k plan membership statisitcs for APEX ARIDYNE CORP WELFARE PLAN

Measure Date Value
2022: APEX ARIDYNE CORP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 177
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 180
Total of all active and inactive participants 2022-06-01 180
Total participants 2022-06-01 180
2020: APEX ARIDYNE CORP WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 160
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 171
Total of all active and inactive participants 2020-06-01 171
Total participants 2020-06-01 171
2019: APEX ARIDYNE CORP WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 160
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 171
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 171
Total participants 2019-06-01 171
2018: APEX ARIDYNE CORP WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 117
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 160
Total of all active and inactive participants 2018-06-01 160
2017: APEX ARIDYNE CORP WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 117
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 117
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 117
2016: APEX ARIDYNE CORP WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 84
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 117
Number of retired or separated participants receiving benefits 2016-06-01 0
Number of other retired or separated participants entitled to future benefits 2016-06-01 0
Total of all active and inactive participants 2016-06-01 117

Measure	Date	Value
2022: APEX ARIDYNE CORP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	177
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	180
Total of all active and inactive participants	2022-06-01	180
Total participants	2022-06-01	180
2020: APEX ARIDYNE CORP WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	160
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	171
Total of all active and inactive participants	2020-06-01	171
Total participants	2020-06-01	171
2019: APEX ARIDYNE CORP WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	160
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	171
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	171
Total participants	2019-06-01	171
2018: APEX ARIDYNE CORP WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	117
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	160
Total of all active and inactive participants	2018-06-01	160
2017: APEX ARIDYNE CORP WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	117
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	117
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	117
2016: APEX ARIDYNE CORP WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	84
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	117
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	117

Financial Data on APEX ARIDYNE CORP WELFARE PLAN

Measure	Date	Value
2018 : APEX ARIDYNE CORP WELFARE PLAN 2018 401k financial data
Total income from all sources	2018-05-31	$0
Total plan assets at end of year	2018-05-31	$0
Total plan assets at beginning of year	2018-05-31	$0
Net plan assets at end of year (total assets less liabilities)	2018-05-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2018-05-31	$0
2017 : APEX ARIDYNE CORP WELFARE PLAN 2017 401k financial data
Total income from all sources	2017-05-31	$0
Total plan assets at end of year	2017-05-31	$0
Total plan assets at beginning of year	2017-05-31	$0
Net plan assets at end of year (total assets less liabilities)	2017-05-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2017-05-31	$0

Form 5500 Responses for APEX ARIDYNE CORP WELFARE PLAN

2022: APEX ARIDYNE CORP WELFARE PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2020: APEX ARIDYNE CORP WELFARE PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Submission has been amended	No
2020-06-01	This submission is the final filing	No
2020-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-06-01	Plan is a collectively bargained plan	No
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: APEX ARIDYNE CORP WELFARE PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Submission has been amended	No
2019-06-01	This submission is the final filing	No
2019-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-06-01	Plan is a collectively bargained plan	No
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2018: APEX ARIDYNE CORP WELFARE PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: APEX ARIDYNE CORP WELFARE PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: APEX ARIDYNE CORP WELFARE PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	First time form 5500 has been submitted	Yes
2016-06-01	Submission has been amended	Yes
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	90
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $93
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

572

Policy instance

Insurance contract or identification number	572
Number of Individuals Covered	119
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,210
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,210
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	107
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $726
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $121

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	86
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,786
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $595

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

Policy contract number

14161995-1001

Policy instance

Insurance contract or identification number	14161995-1001
Number of Individuals Covered	116
Insurance policy start date	2022-06-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,594
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WELLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $537,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,594

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	87
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $2,983
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $977
Amount paid for insurance broker fees	50

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

Policy contract number

14161995-1001

Policy instance

Insurance contract or identification number	14161995-1001
Number of Individuals Covered	90
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $16,305
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WELLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $711,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,305

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

0000572

Policy instance

Insurance contract or identification number	0000572
Number of Individuals Covered	123
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $4,454
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,454
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	104
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $177
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,126
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
Amount paid for insurance broker fees	9

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	109
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,359
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $226

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	106
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $3,312
Total amount of fees paid to insurance company	USD $167
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,208
Amount paid for insurance broker fees	167

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	104
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $192
Total amount of fees paid to insurance company	USD $7
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $128
Amount paid for insurance broker fees	7

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	130
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,627
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,356

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

0000572

Policy instance

Insurance contract or identification number	0000572
Number of Individuals Covered	149
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $5,383
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,383
Insurance broker organization code?	3

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

Policy contract number

14161995-1002

Policy instance

Insurance contract or identification number	14161995-1002
Number of Individuals Covered	18
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $287
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287

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

Policy contract number

14161995-1001

Policy instance

Insurance contract or identification number	14161995-1001
Number of Individuals Covered	71
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $849
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $849

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0149634

Policy instance

Insurance contract or identification number	0149634
Number of Individuals Covered	157
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $5,000
Total amount of fees paid to insurance company	USD $3,000
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,003,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,000
Amount paid for insurance broker fees	3000
Additional information about fees paid to insurance broker	2020 KEY PRODUCER NEW BUSINESS INCENTIVE COMPENSATION - RISK

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

Policy contract number

082086

Policy instance

Insurance contract or identification number	082086
Number of Individuals Covered	171
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $43,678
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,678
Insurance broker organization code?	3

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

Policy contract number

V78467

Policy instance

Insurance contract or identification number	V78467
Number of Individuals Covered	139
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,221
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,221
Insurance broker organization code?	3

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

572

Policy instance

Insurance contract or identification number	572
Number of Individuals Covered	168
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $5,812
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,812
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	149
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,717
Total amount of fees paid to insurance company	USD $194
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,431
Amount paid for insurance broker fees	194
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	114
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $199
Total amount of fees paid to insurance company	USD $60
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66
Insurance broker organization code?	3
Amount paid for insurance broker fees	60

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	110
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $3,108
Total amount of fees paid to insurance company	USD $1,039
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,720
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
Amount paid for insurance broker fees	1039

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

572

Policy instance

Insurance contract or identification number	572
Number of Individuals Covered	159
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $4,410
Total amount of fees paid to insurance company	USD $0
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 $4,410
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	142
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,332
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,110
Insurance broker organization code?	3

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

Policy contract number

V78467

Policy instance

Insurance contract or identification number	V78467
Number of Individuals Covered	137
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $845
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
Commission paid to Insurance Broker	USD $845
Insurance broker organization code?	3

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

Policy contract number

082086

Policy instance

Insurance contract or identification number	082086
Number of Individuals Covered	160
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $37,728
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,728
Insurance broker organization code?	3

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

Policy contract number

50018549

Policy instance

Insurance contract or identification number	50018549
Number of Individuals Covered	91
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $2,650
Total amount of fees paid to insurance company	USD $12
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

082086

Policy instance

Insurance contract or identification number	082086
Number of Individuals Covered	119
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $30,496
Total amount of fees paid to insurance company	USD $5,000
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

572

Policy instance

Insurance contract or identification number	572
Number of Individuals Covered	117
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,767
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	APEX ARIDYNE CORP.
Employer identification number (EIN):	561163708
NAIC Classification:	313000
NAIC Description:	Textile Mills