401k Plan data: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN plan

BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN
Plan identification number	505

BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BRADLEY/DIXIE COMPANY has sponsored the creation of one or more 401k plans.

Company Name: BRADLEY/DIXIE COMPANY

Employer identification number (EIN): 580958295

NAIC Classification: 321900

Additional information about BRADLEY/DIXIE COMPANY

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date: 1965-04-23

Company Identification Number: 461241

Legal Registered Office Address: PO BOX 2328

SAVANNAH
United States of America (USA)
31402-2328

More information about BRADLEY/DIXIE COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2022-01-01
505 2021-01-01
505 2020-01-01
505 2019-01-01
505 2018-01-01
505 2017-01-01 MARK GENTRY MARK GENTRY 2018-10-15
505 2016-01-01 MARK GENTRY MARK GENTRY 2017-11-15
505 2015-01-01 MARK GENTRY MARK GENTRY 2016-10-04
505 2014-01-01 MARK GENTRY MARK GENTRY 2015-10-06
505 2013-01-01 MARK GENTRY
505 2012-01-01 MARK GENTRY
505 2011-01-01 MARK GENTRY
505 2010-01-01 MARK GENTRY
505 2009-01-01 MARK GENTRY

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
505	2022-01-01
505	2021-01-01
505	2020-01-01
505	2019-01-01
505	2018-01-01
505	2017-01-01	MARK GENTRY	MARK GENTRY	2018-10-15
505	2016-01-01	MARK GENTRY	MARK GENTRY	2017-11-15
505	2015-01-01	MARK GENTRY	MARK GENTRY	2016-10-04
505	2014-01-01	MARK GENTRY	MARK GENTRY	2015-10-06
505	2013-01-01	MARK GENTRY
505	2012-01-01	MARK GENTRY
505	2011-01-01	MARK GENTRY
505	2010-01-01	MARK GENTRY
505	2009-01-01	MARK GENTRY

Plan Statistics for BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN

Measure Date Value
2022: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 347
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 331
Total of all active and inactive participants 2022-01-01 331
2021: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 346
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 347
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 2021-01-01 347
2020: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 348
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 346
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 2020-01-01 346
2019: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 350
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 348
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 2019-01-01 348
2018: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 348
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 343
Total of all active and inactive participants 2018-01-01 343
2017: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 340
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 348
Total of all active and inactive participants 2017-01-01 348
2016: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 322
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 340
Total of all active and inactive participants 2016-01-01 340
2015: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 322
Total of all active and inactive participants 2015-01-01 322
2014: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 306
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 273
Total of all active and inactive participants 2014-01-01 273
2013: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 306
Total of all active and inactive participants 2013-01-01 306
2012: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 233
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 234
2011: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 260
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 261
2010: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 283
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 256
Number of retired or separated participants receiving benefits 2010-01-01 5
Total of all active and inactive participants 2010-01-01 261
2009: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 290
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 269
Number of retired or separated participants receiving benefits 2009-01-01 14
Total of all active and inactive participants 2009-01-01 283

Measure	Date	Value
2022: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	347
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	331
Total of all active and inactive participants	2022-01-01	331
2021: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	346
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	347
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	347
2020: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	348
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	346
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	346
2019: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	350
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	348
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	348
2018: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	348
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	343
Total of all active and inactive participants	2018-01-01	343
2017: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	348
Total of all active and inactive participants	2017-01-01	348
2016: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	322
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	340
Total of all active and inactive participants	2016-01-01	340
2015: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	322
Total of all active and inactive participants	2015-01-01	322
2014: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	306
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	273
Total of all active and inactive participants	2014-01-01	273
2013: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	306
Total of all active and inactive participants	2013-01-01	306
2012: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	233
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	234
2011: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	260
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	261
2010: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	283
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	256
Number of retired or separated participants receiving benefits	2010-01-01	5
Total of all active and inactive participants	2010-01-01	261
2009: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	290
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	269
Number of retired or separated participants receiving benefits	2009-01-01	14
Total of all active and inactive participants	2009-01-01	283

Form 5500 Responses for BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN

2022: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Mulitple employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Mulitple employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Mulitple employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Mulitple employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: BRADLEY DIXIE COMPANIES FLEXIBLE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Mulitple employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

78714

Policy instance

Insurance contract or identification number	78714
Number of Individuals Covered	10
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $276
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $276
Insurance broker organization code?	3

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	132
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,581
Total amount of fees paid to insurance company	USD $555
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $62,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,189
Amount paid for insurance broker fees	31
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	560
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,756
Total amount of fees paid to insurance company	USD $369
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $18,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,756
Amount paid for insurance broker fees	369
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	150
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,514
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,514
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

18370

Policy instance

Insurance contract or identification number	18370
Number of Individuals Covered	462
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $26,763
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,763
Insurance broker organization code?	3

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

Policy contract number

EXRK

Policy instance

Insurance contract or identification number	EXRK
Number of Individuals Covered	621
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $21,471
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $715,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,471
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

892450G

Policy instance

Insurance contract or identification number	892450G
Number of Individuals Covered	335
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $29,146
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
Welfare Benefit Premiums Paid to Carrier	USD $209,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,146
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

892450G

Policy instance

Insurance contract or identification number	892450G
Number of Individuals Covered	347
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,376
Total amount of fees paid to insurance company	USD $7,221
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $160,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,376
Amount paid for insurance broker fees	7221
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	157
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,655
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,655
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	560
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,952
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $18,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,952
Additional information about fees paid to insurance broker	SALES OVERIDE
Insurance broker organization code?	3

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	135
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,681
Total amount of fees paid to insurance company	USD $664
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISBURSEMENT
Welfare Benefit Premiums Paid to Carrier	USD $56,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,423
Amount paid for insurance broker fees	59
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL34224

Policy instance

Insurance contract or identification number	HCL34224
Number of Individuals Covered	298
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,703
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $756,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,401
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

78714

Policy instance

Insurance contract or identification number	78714
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $359
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $359
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

18370

Policy instance

Insurance contract or identification number	18370
Number of Individuals Covered	509
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,430
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,430
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5725310

Policy instance

Insurance contract or identification number	5725310
Number of Individuals Covered	344
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $33,568
Total amount of fees paid to insurance company	USD $3,408
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $244,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,568
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	3007

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	163
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,182
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,182
Insurance broker organization code?	3

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	130
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,007
Total amount of fees paid to insurance company	USD $275
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISBURSEMENT
Welfare Benefit Premiums Paid to Carrier	USD $56,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,038
Amount paid for insurance broker fees	7
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL34224

Policy instance

Insurance contract or identification number	HCL34224
Number of Individuals Covered	294
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,302
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $290,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,302
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

78714

Policy instance

Insurance contract or identification number	78714
Number of Individuals Covered	20
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $422
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

18370

Policy instance

Insurance contract or identification number	18370
Number of Individuals Covered	504
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $26,210
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,210
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	560
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $913
Total amount of fees paid to insurance company	USD $424
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $6,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $913
Amount paid for insurance broker fees	424
Additional information about fees paid to insurance broker	SALES OVERIDE
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	350
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $33,276
Total amount of fees paid to insurance company	USD $2,855
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $221,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,042
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	167
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,607
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,607
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	353
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,181
Total amount of fees paid to insurance company	USD $310
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $21,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,181
Amount paid for insurance broker fees	310
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	129
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,265
Total amount of fees paid to insurance company	USD $630
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISBURSEMENT
Welfare Benefit Premiums Paid to Carrier	USD $59,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,082
Amount paid for insurance broker fees	66
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL34224

Policy instance

Insurance contract or identification number	HCL34224
Number of Individuals Covered	308
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,738
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $273,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,738
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

18370

Policy instance

Insurance contract or identification number	18370
Number of Individuals Covered	518
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $27,256
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $209,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,754
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

78714

Policy instance

Insurance contract or identification number	78714
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $454
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $378
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	348
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $29,984
Total amount of fees paid to insurance company	USD $3,878
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,718
Amount paid for insurance broker fees	57
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES NATIONAL INC

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	197
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,568
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,568
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,876
Total amount of fees paid to insurance company	USD $911
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $43,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,699
Amount paid for insurance broker fees	212
Insurance broker organization code?	3
Insurance broker name	HOLLERN & ASSOCIATES INCORPORATED

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	341
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $3,086
Total amount of fees paid to insurance company	USD $402
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $20,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,086
Amount paid for insurance broker fees	402
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

68923-8

Policy instance

Insurance contract or identification number	68923-8
Number of Individuals Covered	296
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIFIC/ AGGREGATE STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $240,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

78714

Policy instance

Insurance contract or identification number	78714
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $781
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $610
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

18370

Policy instance

Insurance contract or identification number	18370
Number of Individuals Covered	495
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $175,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

SL20000250-171

Policy instance

Insurance contract or identification number	SL20000250-171
Number of Individuals Covered	296
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIFIC/ AGGREGATE STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $381,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	322
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $3,197
Total amount of fees paid to insurance company	USD $196
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $21,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,197
Amount paid for insurance broker fees	196
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

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

Policy contract number

68923-8

Policy instance

Insurance contract or identification number	68923-8
Number of Individuals Covered	283
Insurance policy start date	2015-06-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $311,955
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

IOARE-1005-141

Policy instance

Insurance contract or identification number	IOARE-1005-141
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $218,773
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

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	80
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,787
Total amount of fees paid to insurance company	USD $597
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $33,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,734
Amount paid for insurance broker fees	97
Insurance broker organization code?	3
Insurance broker name	HOLLERN & ASSOCIATES

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	202
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,212
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,212
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

AETNA EMPLOYEE ASSISTANCE PLAN (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

65829

Policy instance

Insurance contract or identification number	65829
Number of Individuals Covered	265
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $7,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5725310

Policy instance

Insurance contract or identification number	5725310
Number of Individuals Covered	819
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $35,058
Total amount of fees paid to insurance company	USD $6,289
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $342,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,187
Amount paid for insurance broker fees	27
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INS SERVICES LLC

SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )

Policy contract number

5725310

Policy instance

Insurance contract or identification number	5725310
Number of Individuals Covered	48
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $234
Total amount of fees paid to insurance company	USD $74
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $386
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	USI INS SERVICES LLC

SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )

Policy contract number

5725310

Policy instance

Insurance contract or identification number	5725310
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $136
Total amount of fees paid to insurance company	USD $50
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $264
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	USI INS SERVICES LLC

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-012448-00

Policy instance

Insurance contract or identification number	16-012448-00
Number of Individuals Covered	257
Insurance policy start date	2014-01-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $215,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	194
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,308
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,308
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

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

Policy contract number

IOARE-1005-141

Policy instance

Insurance contract or identification number	IOARE-1005-141
Number of Individuals Covered	273
Insurance policy start date	2014-06-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $299,074
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

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	64
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,324
Total amount of fees paid to insurance company	USD $709
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $27,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,012
Amount paid for insurance broker fees	161
Insurance broker organization code?	3
Insurance broker name	GLENN HOLLERN

SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $436
Total amount of fees paid to insurance company	USD $56
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $308
Insurance broker organization code?	3
Amount paid for insurance broker fees	56
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	846
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $52,545
Total amount of fees paid to insurance company	USD $4,427
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $275,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,416
Insurance broker organization code?	3
Amount paid for insurance broker fees	16
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

AETNA EMPLOYEE ASSISTANCE PLAN (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

845539

Policy instance

Insurance contract or identification number	845539
Number of Individuals Covered	265
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $7,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	55
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $496
Total amount of fees paid to insurance company	USD $61
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $344
Insurance broker organization code?	3
Amount paid for insurance broker fees	61
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	314
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $2,695
Total amount of fees paid to insurance company	USD $186
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $17,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,695
Amount paid for insurance broker fees	186
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

70667

Policy instance

Insurance contract or identification number	70667
Number of Individuals Covered	28
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $286
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $286
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVC USA INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	806
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $26,515
Total amount of fees paid to insurance company	USD $3,241
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $222,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,515
Insurance broker organization code?	3
Amount paid for insurance broker fees	3241
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-012448-00

Policy instance

Insurance contract or identification number	16-012448-00
Number of Individuals Covered	262
Insurance policy start date	2013-06-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $289,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	45
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $165
Total amount of fees paid to insurance company	USD $33
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,086
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
Amount paid for insurance broker fees	33
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

NO4955560

Policy instance

Insurance contract or identification number	NO4955560
Number of Individuals Covered	253
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $185,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	202
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,616
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,616
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

12185

Policy instance

Insurance contract or identification number	12185
Number of Individuals Covered	167
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $4,552
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,552
Insurance broker organization code?	3
Insurance broker name	DDIC BROKER- WELLS FARGO IN SVC USA

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	302
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $3,020
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $20,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,020
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	65
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,197
Total amount of fees paid to insurance company	USD $718
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,142
Amount paid for insurance broker fees	119
Insurance broker organization code?	3
Insurance broker name	JEFFREY M FUQUA

AETNA EMPLOYEE ASSISTANCE PLAN (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

845539

Policy instance

Insurance contract or identification number	845539
Number of Individuals Covered	265
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $8,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	49
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $153
Total amount of fees paid to insurance company	USD $31
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,850
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
Amount paid for insurance broker fees	31
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INS SERVICES USA INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	272
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $2,605
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $16,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,605
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES,INC.

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	61
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,146
Total amount of fees paid to insurance company	USD $541
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,129
Amount paid for insurance broker fees	217
Insurance broker organization code?	3
Insurance broker name	CREATIVE BENEFIT CONSULTANTS INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	272
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18,961
Total amount of fees paid to insurance company	USD $1,963
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $129,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,961
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	195
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,112
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,112
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N04955560

Policy instance

Insurance contract or identification number	N04955560
Number of Individuals Covered	234
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS
Welfare Benefit Premiums Paid to Carrier	USD $413,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA EMPLOYEE ASSISTANCE PLAN (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

845539

Policy instance

Insurance contract or identification number	845539
Number of Individuals Covered	265
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $7,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

00667

Policy instance

Insurance contract or identification number	00667
Number of Individuals Covered	31
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $675
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $675
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA INC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

12185

Policy instance

Insurance contract or identification number	12185
Number of Individuals Covered	158
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,176
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,176
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES,INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,023
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $17,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

11-03657

Policy instance

Insurance contract or identification number	11-03657
Number of Individuals Covered	149
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,298
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N04955560

Policy instance

Insurance contract or identification number	N04955560
Number of Individuals Covered	227
Insurance policy start date	2011-06-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS
Welfare Benefit Premiums Paid to Carrier	USD $228,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	180
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,919
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,151
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

CLI50345

Policy instance

Insurance contract or identification number	CLI50345
Number of Individuals Covered	223
Insurance policy start date	2011-01-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	260
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $15,265
Total amount of fees paid to insurance company	USD $2,052
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $103,595
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

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	48
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,982
Total amount of fees paid to insurance company	USD $179
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00667

Policy instance

Insurance contract or identification number	00667
Number of Individuals Covered	28
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $722
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00667

Policy instance

Insurance contract or identification number	00667
Number of Individuals Covered	32
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $482
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $482
Insurance broker organization code?	3
Insurance broker name	WACHOVIA INSURANCE SERVICES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

COA001986

Policy instance

Insurance contract or identification number	COA001986
Number of Individuals Covered	256
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,837
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $17,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,837
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES,INC.

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

M103570

Policy instance

Insurance contract or identification number	M103570
Number of Individuals Covered	185
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,777
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,777
Insurance broker name	WACHOVIA INSURANCE SERVICES, INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

11-03657

Policy instance

Insurance contract or identification number	11-03657
Number of Individuals Covered	150
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,731
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,731
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES,INC.

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

Policy contract number

CLI50345

Policy instance

Insurance contract or identification number	CLI50345
Number of Individuals Covered	233
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05725310

Policy instance

Insurance contract or identification number	TM05725310
Number of Individuals Covered	254
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $13,996
Total amount of fees paid to insurance company	USD $1,880
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $92,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,996
Amount paid for insurance broker fees	15
Additional information about fees paid to insurance broker	NONMONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES,INC.

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

Policy contract number

E7264831

Policy instance

Insurance contract or identification number	E7264831
Number of Individuals Covered	44
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,990
Total amount of fees paid to insurance company	USD $115
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $912
Amount paid for insurance broker fees	74
Insurance broker organization code?	3
Insurance broker name	GLENN STALTARE

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Company Name:	BRADLEY/DIXIE COMPANY
Employer identification number (EIN):	580958295
NAIC Classification:	321900

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:	1965-04-23
Company Identification Number:	461241
Legal Registered Office Address:	PO BOX 2328 SAVANNAH United States of America (USA) 31402-2328