401k Plan data: FLEXIBLE SPENDING PLAN plan

FLEXIBLE SPENDING PLAN 401k Plan overview

Plan Name	FLEXIBLE SPENDING PLAN
Plan identification number	501

FLEXIBLE SPENDING PLAN Benefits

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

401k Sponsoring company profile

PALMETTO CITIZENS FEDERAL CREDIT UNION has sponsored the creation of one or more 401k plans.

Company Name: PALMETTO CITIZENS FEDERAL CREDIT UNION

Employer identification number (EIN): 570314480

NAIC Classification: 522130
NAIC Description: Credit Unions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FLEXIBLE SPENDING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 CLINT CLAYBORN CLINT CLAYBORN 2018-07-27
501 2016-01-01 CLINT CLAYBORN CLINT CLAYBORN 2017-06-08
501 2015-01-01 CLINT CLAYBORN CLINT CLAYBORN 2016-07-29
501 2014-01-01 CLINT CLAYBORN CLINT CLAYBORN 2015-07-30
501 2013-01-01 CLINT CLAYBORN CLINT CLAYBORN 2014-07-23
501 2012-01-01 CLINT CLAYBORN CLINT CLAYBORN 2013-07-30
501 2011-01-01 CLINT CLAYBORN CLINT CLAYBORN 2012-09-13
501 2009-01-01 CLINT CLAYBORN CLINT CLAYBORN 2010-08-02

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2018-07-27
501	2016-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2017-06-08
501	2015-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2016-07-29
501	2014-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2015-07-30
501	2013-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2014-07-23
501	2012-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2013-07-30
501	2011-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2012-09-13
501	2009-01-01	CLINT CLAYBORN	CLINT CLAYBORN	2010-08-02

Plan Statistics for FLEXIBLE SPENDING PLAN

401k plan membership statisitcs for FLEXIBLE SPENDING PLAN

Measure Date Value
2022: FLEXIBLE SPENDING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 282
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 297
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 297
2021: FLEXIBLE SPENDING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 270
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 282
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 282
2020: FLEXIBLE SPENDING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 270
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 270
2019: FLEXIBLE SPENDING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 269
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 2019-01-01 269
2018: FLEXIBLE SPENDING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 273
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 273
2017: FLEXIBLE SPENDING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 242
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 256
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 256
2016: FLEXIBLE SPENDING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 242
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 242
2015: FLEXIBLE SPENDING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 226
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 234
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 234
2014: FLEXIBLE SPENDING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 226
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 226
2013: FLEXIBLE SPENDING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 215
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 222
Total of all active and inactive participants 2013-01-01 222
2012: FLEXIBLE SPENDING PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 215
Total of all active and inactive participants 2012-01-01 215
2011: FLEXIBLE SPENDING PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 212
Total of all active and inactive participants 2011-01-01 212
2009: FLEXIBLE SPENDING PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 213
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 216
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 216

Measure	Date	Value
2022: FLEXIBLE SPENDING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	282
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	297
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	297
2021: FLEXIBLE SPENDING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	270
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	282
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	282
2020: FLEXIBLE SPENDING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	270
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	270
2019: FLEXIBLE SPENDING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	269
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	269
2018: FLEXIBLE SPENDING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	273
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	273
2017: FLEXIBLE SPENDING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	242
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	256
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	256
2016: FLEXIBLE SPENDING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	242
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	242
2015: FLEXIBLE SPENDING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	226
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	234
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	234
2014: FLEXIBLE SPENDING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	226
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	226
2013: FLEXIBLE SPENDING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	215
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	222
Total of all active and inactive participants	2013-01-01	222
2012: FLEXIBLE SPENDING PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	215
Total of all active and inactive participants	2012-01-01	215
2011: FLEXIBLE SPENDING PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	212
Total of all active and inactive participants	2011-01-01	212
2009: FLEXIBLE SPENDING PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	213
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	216
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	216

Form 5500 Responses for FLEXIBLE SPENDING PLAN

2022: FLEXIBLE SPENDING PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: FLEXIBLE SPENDING PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: FLEXIBLE SPENDING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: FLEXIBLE SPENDING PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: FLEXIBLE SPENDING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: FLEXIBLE SPENDING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: FLEXIBLE SPENDING PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: FLEXIBLE SPENDING PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: FLEXIBLE SPENDING PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: FLEXIBLE SPENDING PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: FLEXIBLE SPENDING PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: FLEXIBLE SPENDING PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: FLEXIBLE SPENDING PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	269
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	278
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,428
Are there contracts with allocated funds for individual policies?	1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,428
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

390257111

Policy instance

Insurance contract or identification number	390257111
Number of Individuals Covered	297
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,883
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,599
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00305

Policy instance

Insurance contract or identification number	00305
Number of Individuals Covered	263
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	259
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,281
Are there contracts with allocated funds for individual policies?	1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,281
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

390257111

Policy instance

Insurance contract or identification number	390257111
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,163
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,198
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00305

Policy instance

Insurance contract or identification number	00305
Number of Individuals Covered	267
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	266
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	261
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $165
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $165
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00305

Policy instance

Insurance contract or identification number	00305
Number of Individuals Covered	260
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

3902571111

Policy instance

Insurance contract or identification number	3902571111
Number of Individuals Covered	270
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,654
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,837
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	259
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,139
Are there contracts with allocated funds for individual policies?	1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,133
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	265
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,429
Are there contracts with allocated funds for individual policies?	1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,128
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	269
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,394
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,394
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

0661

Policy instance

Insurance contract or identification number	0661
Number of Individuals Covered	264
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $117,933
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $117,933
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

3902571111

Policy instance

Insurance contract or identification number	3902571111
Number of Individuals Covered	267
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,157
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,162
Insurance broker organization code?	3

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	250
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,957
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,957
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	250
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,657
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC AD&D AND DEPENDENT LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,657
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	251
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $100,341
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $100,341
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	252
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,322
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,322
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	256
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $17,324
Are there contracts with allocated funds for individual policies?	1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,233
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTH PLAN

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	234
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $2,620
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $31,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,620
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	234
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $3,800
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,800
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	229
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,526
Total amount of fees paid to insurance company	USD $10
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,852
Amount paid for insurance broker fees	10
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTH PLAN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	230
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $1,253
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,253
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	230
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $81,881
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,881
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	226
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,459
Total amount of fees paid to insurance company	USD $10
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,795
Amount paid for insurance broker fees	10
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTH PLAN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	223
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,255
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,255
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	223
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $76,429
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,429
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	8
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,984
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $25,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,984
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	8
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,946
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,946
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	222
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,349
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $31,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,349
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	222
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,574
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,574
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	222
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,250
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,250
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

6021482181

Policy instance

Insurance contract or identification number	6021482181
Number of Individuals Covered	220
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,641
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,696
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTH PLAN

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

Policy contract number

E7069214

Policy instance

Insurance contract or identification number	E7069214
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $38
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3
Insurance broker name	GARY M HARDEMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	160
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $68,713
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,713
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	214
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $3,406
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,406
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	214
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $2,197
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $28,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,197
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	210
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $68,462
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,462
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	215
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $1,173
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,173
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

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

Policy contract number

E7069214

Policy instance

Insurance contract or identification number	E7069214
Number of Individuals Covered	2
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $45
Total amount of fees paid to insurance company	USD $4
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Amount paid for insurance broker fees	4
Insurance broker organization code?	3
Insurance broker name	DEBI H. MONGELLI

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

Policy contract number

246-6092-00

Policy instance

Insurance contract or identification number	246-6092-00
Number of Individuals Covered	213
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $3,702
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,702
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

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

Policy contract number

LTD 122002

Policy instance

Insurance contract or identification number	LTD 122002
Number of Individuals Covered	211
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $2,961
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,107
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

E7069214

Policy instance

Insurance contract or identification number	E7069214
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $1
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 148451

Policy instance

Insurance contract or identification number	GL 148451
Number of Individuals Covered	211
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $1,954
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $24,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	208
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $50,775
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	211
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,180
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

246-6092-00

Policy instance

Insurance contract or identification number	246-6092-00
Number of Individuals Covered	212
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,793
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER SPECIFY
Welfare Benefit Premiums Paid to Carrier	USD $122,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA588

Policy instance

Insurance contract or identification number	BA588
Number of Individuals Covered	206
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $48,908
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,908
Insurance broker organization code?	3
Insurance broker name	BLUECHOICE HEALTHPLAN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12028019

Policy instance

Insurance contract or identification number	12028019
Number of Individuals Covered	205
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,655
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,484
Insurance broker organization code?	3
Insurance broker name	ROBERT O. TINDALL

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

Policy contract number

246-6092-00

Policy instance

Insurance contract or identification number	246-6092-00
Number of Individuals Covered	207
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,539
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER SPECIFY DEPEND LIFE
Welfare Benefit Premiums Paid to Carrier	USD $170,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,539
Insurance broker organization code?	3
Insurance broker name	ROBERT O TINDALL

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

Policy contract number

E7069214

Policy instance

Insurance contract or identification number	E7069214
Number of Individuals Covered	207
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $120
Total amount of fees paid to insurance company	USD $2
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	INSURANCE FEES
Insurance broker organization code?	3
Insurance broker name	DEBI H. MONGELLI

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Company Name:	PALMETTO CITIZENS FEDERAL CREDIT UNION
Employer identification number (EIN):	570314480
NAIC Classification:	522130
NAIC Description:	Credit Unions