401k Plan data: MACON BANK EMPLOYEE BENEFIT PLAN plan

MACON BANK EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	MACON BANK EMPLOYEE BENEFIT PLAN
Plan identification number	502

MACON BANK EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Other welfare benefit cover

401k Sponsoring company profile

ENTEGRA BANK has sponsored the creation of one or more 401k plans.

Company Name: ENTEGRA BANK

Employer identification number (EIN): 562004870

NAIC Classification: 522120
NAIC Description: Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MACON BANK EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-01-01
502 2018-06-01
502 2017-06-01 HOLLY ROGERS
502 2016-06-01 HOLLY ROGERS HOLLY ROGERS 2017-11-03
502 2015-06-01 HOLLY ROGERS HOLLY ROGERS 2016-09-23
502 2014-06-01 HOLLY ROGERS HOLLY ROGERS 2015-08-17
502 2013-06-01 HOLLY ROGERS HOLLY ROGERS 2014-10-06
502 2012-06-01 HOLLY ROGERS HOLLY ROGERS 2013-11-13
502 2011-06-01 HOLLY ROGERS
502 2009-06-01 HOLLY ROGERS
502 2008-06-01 HOLLY ROGERS
502 2004-06-01 HOLLY ROGERS

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2019-01-01
502	2018-06-01
502	2017-06-01	HOLLY ROGERS
502	2016-06-01	HOLLY ROGERS	HOLLY ROGERS	2017-11-03
502	2015-06-01	HOLLY ROGERS	HOLLY ROGERS	2016-09-23
502	2014-06-01	HOLLY ROGERS	HOLLY ROGERS	2015-08-17
502	2013-06-01	HOLLY ROGERS	HOLLY ROGERS	2014-10-06
502	2012-06-01	HOLLY ROGERS	HOLLY ROGERS	2013-11-13
502	2011-06-01	HOLLY ROGERS
502	2009-06-01	HOLLY ROGERS
502	2008-06-01	HOLLY ROGERS
502	2004-06-01	HOLLY ROGERS

Plan Statistics for MACON BANK EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for MACON BANK EMPLOYEE BENEFIT PLAN

Measure Date Value
2019: MACON BANK EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 274
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 0
2018: MACON BANK EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 277
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 274
Total of all active and inactive participants 2018-06-01 274
Total participants 2018-06-01 274
2017: MACON BANK EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 255
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 277
Total of all active and inactive participants 2017-06-01 277
Total participants 2017-06-01 277
2016: MACON BANK EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 240
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 267
Total of all active and inactive participants 2016-06-01 267
Total participants 2016-06-01 267
2015: MACON BANK EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 193
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 224
Total of all active and inactive participants 2015-06-01 224
Total participants 2015-06-01 224
2014: MACON BANK EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 189
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 193
Total of all active and inactive participants 2014-06-01 193
Total participants 2014-06-01 193
2013: MACON BANK EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 179
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 189
Total of all active and inactive participants 2013-06-01 189
Total participants 2013-06-01 189
2012: MACON BANK EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 181
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 185
Number of retired or separated participants receiving benefits 2012-06-01 0
Number of other retired or separated participants entitled to future benefits 2012-06-01 0
Total of all active and inactive participants 2012-06-01 185
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-06-01 0
Total participants 2012-06-01 185
2011: MACON BANK EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 174
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 169
Number of retired or separated participants receiving benefits 2011-06-01 0
Number of other retired or separated participants entitled to future benefits 2011-06-01 0
Total of all active and inactive participants 2011-06-01 169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-06-01 0
Total participants 2011-06-01 169
2009: MACON BANK EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 180
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 174
Number of retired or separated participants receiving benefits 2009-06-01 0
Number of other retired or separated participants entitled to future benefits 2009-06-01 0
Total of all active and inactive participants 2009-06-01 174
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-06-01 0
Total participants 2009-06-01 174
2008: MACON BANK EMPLOYEE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year 2008-06-01 189
Total number of active participants reported on line 7a of the Form 5500 2008-06-01 180
Number of retired or separated participants receiving benefits 2008-06-01 0
Number of other retired or separated participants entitled to future benefits 2008-06-01 0
Total of all active and inactive participants 2008-06-01 180
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2008-06-01 0
Total participants 2008-06-01 180
2004: MACON BANK EMPLOYEE BENEFIT PLAN 2004 401k membership
Total participants, beginning-of-year 2004-06-01 181
Total number of active participants reported on line 7a of the Form 5500 2004-06-01 179
Number of retired or separated participants receiving benefits 2004-06-01 0
Number of other retired or separated participants entitled to future benefits 2004-06-01 0
Total of all active and inactive participants 2004-06-01 179
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2004-06-01 0
Total participants 2004-06-01 179

Measure	Date	Value
2019: MACON BANK EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	0
2018: MACON BANK EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	277
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	274
Total of all active and inactive participants	2018-06-01	274
Total participants	2018-06-01	274
2017: MACON BANK EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	255
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	277
Total of all active and inactive participants	2017-06-01	277
Total participants	2017-06-01	277
2016: MACON BANK EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	240
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	267
Total of all active and inactive participants	2016-06-01	267
Total participants	2016-06-01	267
2015: MACON BANK EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	193
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	224
Total of all active and inactive participants	2015-06-01	224
Total participants	2015-06-01	224
2014: MACON BANK EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	189
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	193
Total of all active and inactive participants	2014-06-01	193
Total participants	2014-06-01	193
2013: MACON BANK EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	179
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	189
Total of all active and inactive participants	2013-06-01	189
Total participants	2013-06-01	189
2012: MACON BANK EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	181
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	185
Number of retired or separated participants receiving benefits	2012-06-01	0
Number of other retired or separated participants entitled to future benefits	2012-06-01	0
Total of all active and inactive participants	2012-06-01	185
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-06-01	0
Total participants	2012-06-01	185
2011: MACON BANK EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	174
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	169
Number of retired or separated participants receiving benefits	2011-06-01	0
Number of other retired or separated participants entitled to future benefits	2011-06-01	0
Total of all active and inactive participants	2011-06-01	169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-06-01	0
Total participants	2011-06-01	169
2009: MACON BANK EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	180
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	174
Number of retired or separated participants receiving benefits	2009-06-01	0
Number of other retired or separated participants entitled to future benefits	2009-06-01	0
Total of all active and inactive participants	2009-06-01	174
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-06-01	0
Total participants	2009-06-01	174
2008: MACON BANK EMPLOYEE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year	2008-06-01	189
Total number of active participants reported on line 7a of the Form 5500	2008-06-01	180
Number of retired or separated participants receiving benefits	2008-06-01	0
Number of other retired or separated participants entitled to future benefits	2008-06-01	0
Total of all active and inactive participants	2008-06-01	180
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2008-06-01	0
Total participants	2008-06-01	180
2004: MACON BANK EMPLOYEE BENEFIT PLAN 2004 401k membership
Total participants, beginning-of-year	2004-06-01	181
Total number of active participants reported on line 7a of the Form 5500	2004-06-01	179
Number of retired or separated participants receiving benefits	2004-06-01	0
Number of other retired or separated participants entitled to future benefits	2004-06-01	0
Total of all active and inactive participants	2004-06-01	179
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2004-06-01	0
Total participants	2004-06-01	179

Form 5500 Responses for MACON BANK EMPLOYEE BENEFIT PLAN

2019: MACON BANK EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: MACON BANK EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Submission has been amended	No
2018-06-01	This submission is the final filing	No
2018-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-06-01	Plan is a collectively bargained plan	No
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: MACON BANK EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Submission has been amended	No
2017-06-01	This submission is the final filing	No
2017-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-06-01	Plan is a collectively bargained plan	No
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: MACON BANK EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Submission has been amended	No
2016-06-01	This submission is the final filing	No
2016-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-06-01	Plan is a collectively bargained plan	No
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: MACON BANK EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	No
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: MACON BANK EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Submission has been amended	No
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: MACON BANK EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Submission has been amended	No
2013-06-01	This submission is the final filing	No
2013-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-06-01	Plan is a collectively bargained plan	No
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: MACON BANK EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Submission has been amended	No
2012-06-01	This submission is the final filing	No
2012-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-06-01	Plan is a collectively bargained plan	No
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: MACON BANK EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Submission has been amended	No
2011-06-01	This submission is the final filing	No
2011-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-06-01	Plan is a collectively bargained plan	No
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2009: MACON BANK EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	Submission has been amended	No
2009-06-01	This submission is the final filing	No
2009-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-06-01	Plan is a collectively bargained plan	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes
2008: MACON BANK EMPLOYEE BENEFIT PLAN 2008 form 5500 responses
2008-06-01	Type of plan entity	Single employer plan
2008-06-01	Submission has been amended	No
2008-06-01	This submission is the final filing	No
2008-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-06-01	Plan is a collectively bargained plan	No
2008-06-01	Plan funding arrangement – Insurance	Yes
2008-06-01	Plan benefit arrangement – Insurance	Yes
2004: MACON BANK EMPLOYEE BENEFIT PLAN 2004 form 5500 responses
2004-06-01	Type of plan entity	Single employer plan
2004-06-01	Submission has been amended	No
2004-06-01	This submission is the final filing	No
2004-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-06-01	Plan is a collectively bargained plan	No
2004-06-01	Plan funding arrangement – Insurance	Yes
2004-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

G000-BCGX

Policy instance

Insurance contract or identification number	G000-BCGX
Number of Individuals Covered	231
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $8,304
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $83,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,304
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000152906

Policy instance

Insurance contract or identification number	0000152906
Number of Individuals Covered	3
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $72
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	SUPPLEMENTAL INCOME PROTECTION
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 $1,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	1
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $0
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	SUPPLEMENTAL INCOME PROTECTION
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 $947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	167
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $13,817
Total amount of fees paid to insurance company	USD $545
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	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $98,924
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
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	3
Amount paid for insurance broker fees	59

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	1
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $5
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	SUPPLEMENTAL INCOME PROTECTION
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 $1,774
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
Insurance broker organization code?	3

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

Policy contract number

G000-BCGX

Policy instance

Insurance contract or identification number	G000-BCGX
Number of Individuals Covered	274
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $16,125
Total amount of fees paid to insurance company	USD $296
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $161,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,125
Amount paid for insurance broker fees	2096
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	2
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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	SUPPLEMENTAL INCOME PROTECTION
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 $245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	3
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $154
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	SUPPLEMENTAL INCOME PROTECTION
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 $3,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $138
Insurance broker organization code?	3

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	29
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $4,724
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	LONG TERM CARE
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 $33,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,724
Insurance broker organization code?	3

COLONIAL LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62047 )

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	183
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $28,488
Total amount of fees paid to insurance company	USD $1,290
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	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $171,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,605
Amount paid for insurance broker fees	25
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	1
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $7
Total amount of fees paid to insurance company	USD $0
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	SUPPLEMENTAL INCOME PROTECTION
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 $2,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

69489-4

Policy instance

Insurance contract or identification number	69489-4
Number of Individuals Covered	26
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $4,092
Total amount of fees paid to insurance company	USD $5,909
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $118,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,092
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	3
Insurance broker name	MOSAID GROUP SERVICES, LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	2
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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
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 $2,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62047 )

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	186
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $27,908
Total amount of fees paid to insurance company	USD $736
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	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $153,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,940
Insurance broker organization code?	3
Amount paid for insurance broker fees	340
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	BARBARA HART

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,574
Total amount of fees paid to insurance company	USD $0
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	LONG TERM CARE
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 $23,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,841
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	3
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $171
Total amount of fees paid to insurance company	USD $0
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	SUPPLEMENTAL INCOME PROTECTION
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 $3,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	31
Insurance policy start date	2015-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $2,502
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
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 $16,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,502
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	224
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $9,088
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $70,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,727
Insurance broker organization code?	3
Insurance broker name	DOUGLAS R. FRANKLIN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	3
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $56
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME BENEFIT
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 $3,755
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
Insurance broker organization code?	3
Insurance broker name	THE WAYAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	1
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $7
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME BENEFIT
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 $2,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	6
Insurance policy start date	2015-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $1,096
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME BENEFIT
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 $4,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $987
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC,

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	145
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $22,705
Total amount of fees paid to insurance company	USD $1,065
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $85,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,818
Insurance broker organization code?	3
Amount paid for insurance broker fees	255
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	BARBARA HART

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	101
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $5,937
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 AND 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 $34,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,937
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	124
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $13,763
Total amount of fees paid to insurance company	USD $488
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $85,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,852
Insurance broker organization code?	3
Amount paid for insurance broker fees	152
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	LOIS ANN KEENAN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	4
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $627
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $2,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $565
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	4
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $27
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $2,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	3
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $153
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $3,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153
Insurance broker organization code?	3
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	106
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $5,092
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 AND 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 $29,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,092
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	22
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $2,429
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
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 $14,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,429
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	189
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $7,787
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $62,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,488
Insurance broker organization code?	3
Insurance broker name	DOUGLAS R. FRANKLIN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	3
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $167
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $3,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $167
Insurance broker organization code?	3
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	17
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,718
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
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 $15,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,718
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	111
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $13,867
Total amount of fees paid to insurance company	USD $430
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
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 $82,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,877
Insurance broker organization code?	3
Amount paid for insurance broker fees	130
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	JANE A PETERSON-OGLE

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	3
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $523
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $1,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $471
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	13
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $57
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
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 $3,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC.

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	105
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $5,344
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 AND 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 $31,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,344
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	179
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $8,249
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND 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 $66,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,927
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	170
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $7,254
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $55,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,979
Insurance broker organization code?	3
Insurance broker name	DOUGLAS R. FRANKLIN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	1
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $114
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $103
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	15
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $4,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $115
Insurance broker organization code?	3
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK, INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	3
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $167
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $3,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $167
Insurance broker organization code?	3
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	111
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $5,407
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $31,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,407
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	22
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,469
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,469
Insurance broker organization code?	3
Insurance broker name	EBENCONCEPTS COMPANY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	102
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $11,533
Total amount of fees paid to insurance company	USD $285
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $74,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,143
Insurance broker organization code?	3
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	D M BURRELL & ASSOCIATES

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	162
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $7,432
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $55,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	94
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $6,542
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $40,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	1
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $167
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $3,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	16
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $140
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $5,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	100
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $8,923
Total amount of fees paid to insurance company	USD $342
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $69,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	22
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $2,317
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $13,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	173
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $6,753
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $56,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	3
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $237
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $3,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	17
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $166
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $5,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

152906

Policy instance

Insurance contract or identification number	152906
Number of Individuals Covered	1
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $38
Other welfare benefits provided	SUPPLEMENTAL INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $85
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	103
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $5,995
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $39,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	103
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $9,137
Total amount of fees paid to insurance company	USD $370
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $65,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $2,298
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	105
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $5,330
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $42,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,330
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	119
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $11,866
Total amount of fees paid to insurance company	USD $544
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $68,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,720
Insurance broker organization code?	1
Amount paid for insurance broker fees	94
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker name	JANE PETERSON

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	24
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $2,256
Other welfare benefits provided	LONG-TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $15,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,256
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	22
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $290
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $5,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $265
Insurance broker organization code?	1
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	180
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $7,987
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $85,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,598
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R. FRANKLIN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	5
Insurance policy start date	2008-06-01
Insurance policy end date	2009-05-31
Total amount of commissions paid to insurance broker	USD $512
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $5,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $512
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	135
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $10,690
Total amount of fees paid to insurance company	USD $1,497
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $63,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,271
Amount paid for insurance broker fees	523
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	1
Insurance broker name	KENNETH P BARLETT

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	102
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $5,311
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $35,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,311
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	189
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $7,955
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $78,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,565
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R. FRANKLIN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	6
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $571
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $5,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $571
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	24
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $2,120
Other welfare benefits provided	LONG-TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,120
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	28
Insurance policy start date	2007-06-01
Insurance policy end date	2008-05-31
Total amount of commissions paid to insurance broker	USD $302
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $5,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $277
Insurance broker organization code?	1
Insurance broker name	CHAMPAGNE FINANCIAL NETWORK INC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	7
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $1,662
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $8,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,662
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	182
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $7,943
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $80,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,568
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R. FRANKLIN

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	121
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $10,959
Total amount of fees paid to insurance company	USD $1,277
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $65,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,299
Amount paid for insurance broker fees	322
Additional information about fees paid to insurance broker	BONUS AND NONCASH INCENTIVES
Insurance broker organization code?	1
Insurance broker name	JANE PATTERSON

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	24
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $2,892
Other welfare benefits provided	LONG-TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $19,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,892
Insurance broker organization code?	1
Insurance broker name	THE WAYLAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	29
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $442
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $8,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $404
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R FRANKLIN

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	102
Insurance policy start date	2006-06-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $6,584
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $43,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,584
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	102
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $3,969
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $26,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,969
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	97
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $13,056
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $54,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,536
Insurance broker organization code?	1
Insurance broker name	HOPE REYNOLDS

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

Policy contract number

039062

Policy instance

Insurance contract or identification number	039062
Number of Individuals Covered	24
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $2,153
Other welfare benefits provided	LONG-TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $12,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,153
Insurance broker organization code?	1
Insurance broker name	THE WAYLAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

143355

Policy instance

Insurance contract or identification number	143355
Number of Individuals Covered	7
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $4,059
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $6,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,059
Insurance broker name	THE WAYAH AGENCY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

131929

Policy instance

Insurance contract or identification number	131929
Number of Individuals Covered	32
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $1,187
Other welfare benefits provided	SUPPLEMENTAL INSURANCE PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $10,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,091
Insurance broker organization code?	1
Insurance broker name	DOUGLASS R FRANKLIN

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	177
Insurance policy start date	2005-06-01
Insurance policy end date	2006-05-31
Total amount of commissions paid to insurance broker	USD $5,900
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $53,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,629
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R. FRANKLIN

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

Policy contract number

E7730690

Policy instance

Insurance contract or identification number	E7730690
Number of Individuals Covered	93
Insurance policy start date	2004-06-01
Insurance policy end date	2005-05-31
Total amount of commissions paid to insurance broker	USD $16,283
Other welfare benefits provided	VARIOUS EMPLOYEE PAID SUPPLEMENTAL (LIFE AND ACCIDENT INSURANCE)
Welfare Benefit Premiums Paid to Carrier	USD $50,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,212
Insurance broker organization code?	1
Insurance broker name	KENNETH P BARLETT

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

Policy contract number

401019

Policy instance

Insurance contract or identification number	401019
Number of Individuals Covered	179
Insurance policy start date	2004-06-01
Insurance policy end date	2005-05-31
Total amount of commissions paid to insurance broker	USD $6,503
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $60,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,193
Insurance broker organization code?	1
Insurance broker name	DOUGLAS R. FRANKLIN

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

Policy contract number

526933

Policy instance

Insurance contract or identification number	526933
Number of Individuals Covered	102
Insurance policy start date	2004-06-01
Insurance policy end date	2005-05-31
Total amount of commissions paid to insurance broker	USD $4,655
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $31,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,655
Insurance broker organization code?	1
Insurance broker name	THE WAYAH AGENCY

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Company Name:	ENTEGRA BANK
Employer identification number (EIN):	562004870
NAIC Classification:	522120
NAIC Description:	Savings Institutions