ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN
Plan identification number	501

ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

E.S.P. INC. ENRICHMENT SERVICES PROGRAM INC. has sponsored the creation of one or more 401k plans.

Company Name:	E.S.P. INC. ENRICHMENT SERVICES PROGRAM INC.
Employer identification number (EIN):	581020547
NAIC Classification:	624100
NAIC Description:	Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-04-01
501	2021-04-01
501	2020-04-01
501	2019-04-01
501	2018-04-01
501	2018-04-01
501	2017-04-01	BELVA DORSEY
501	2016-04-01	BELVA DORSEY
501	2015-04-01	BELVA DORSEY
501	2014-04-01	BELVA DORSEY
501	2013-04-01	BELVA DORSEY
501	2012-04-01	BELVA DORSEY
501	2010-04-01	BELVA DORSEY
501	2009-04-01	BELVA DORSEY
501	2009-04-01	BELVA DORSEY
501	2009-04-01	BELVA DORSEY
501	2009-04-01	BELVA DORSEY
501	2009-04-01	BELVA DORSEY

Plan Statistics for ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN

Measure	Date	Value
2022: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-04-01	315
Total number of active participants reported on line 7a of the Form 5500	2022-04-01	402
Total of all active and inactive participants	2022-04-01	402
Total participants	2022-04-01	402
2021: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-04-01	306
Total number of active participants reported on line 7a of the Form 5500	2021-04-01	314
Number of retired or separated participants receiving benefits	2021-04-01	1
Total of all active and inactive participants	2021-04-01	315
Total participants	2021-04-01	315
2020: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	234
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	302
Number of retired or separated participants receiving benefits	2020-04-01	4
Total of all active and inactive participants	2020-04-01	306
Total participants	2020-04-01	306
2019: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	217
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	234
Total of all active and inactive participants	2019-04-01	234
Total participants	2019-04-01	234
2018: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	223
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	217
Total of all active and inactive participants	2018-04-01	217
Total participants	2018-04-01	217
2017: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	196
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	223
Total of all active and inactive participants	2017-04-01	223
Total participants	2017-04-01	223
2016: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	195
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	196
Total of all active and inactive participants	2016-04-01	196
Total participants	2016-04-01	196
2015: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	193
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	195
Total of all active and inactive participants	2015-04-01	195
Total participants	2015-04-01	0
2014: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	192
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	193
Total of all active and inactive participants	2014-04-01	193
Total participants	2014-04-01	0
2013: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	201
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	192
Total of all active and inactive participants	2013-04-01	192
Total participants	2013-04-01	0
2012: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	198
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	201
Total of all active and inactive participants	2012-04-01	201
Total participants	2012-04-01	0
2010: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-04-01	210
Total number of active participants reported on line 7a of the Form 5500	2010-04-01	232
Total of all active and inactive participants	2010-04-01	232
Total participants	2010-04-01	232
2009: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-04-01	275
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	210
Total of all active and inactive participants	2009-04-01	210
Total participants	2009-04-01	210

Financial Data on ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN

Measure	Date	Value
2013 : ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2013 401k financial data
Value of total assets at end of year	2013-03-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-03-31	No
Was this plan covered by a fidelity bond	2013-03-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-03-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-03-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-03-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-03-31	No
Were any leases to which the plan was party in default or uncollectible	2013-03-31	No
Value of interest in common/collective trusts at end of year	2013-03-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-03-31	No
Was there a failure to transmit to the plan any participant contributions	2013-03-31	No
Has the plan failed to provide any benefit when due under the plan	2013-03-31	No
Did the plan have assets held for investment	2013-03-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-03-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-03-31	No

Form 5500 Responses for ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN

2022: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-04-01	Type of plan entity	Single employer plan
2022-04-01	Submission has been amended	No
2022-04-01	This submission is the final filing	No
2022-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-04-01	Plan is a collectively bargained plan	No
2022-04-01	Plan funding arrangement – Insurance	Yes
2022-04-01	Plan benefit arrangement – Insurance	Yes
2021: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-04-01	Type of plan entity	Single employer plan
2021-04-01	Submission has been amended	No
2021-04-01	This submission is the final filing	No
2021-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-04-01	Plan is a collectively bargained plan	No
2021-04-01	Plan funding arrangement – Insurance	Yes
2021-04-01	Plan benefit arrangement – Insurance	Yes
2020: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
2020-04-01	Submission has been amended	No
2020-04-01	This submission is the final filing	No
2020-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-04-01	Plan is a collectively bargained plan	No
2020-04-01	Plan funding arrangement – Insurance	Yes
2020-04-01	Plan benefit arrangement – Insurance	Yes
2019: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	Submission has been amended	No
2019-04-01	This submission is the final filing	No
2019-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-04-01	Plan is a collectively bargained plan	No
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes
2018: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Submission has been amended	No
2018-04-01	This submission is the final filing	No
2018-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-04-01	Plan is a collectively bargained plan	No
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes
2017: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2016: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2015: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2014: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2013: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2012: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2010: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-04-01	Type of plan entity	Single employer plan
2010-04-01	Plan funding arrangement – Insurance	Yes
2010-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-04-01	Plan benefit arrangement – Insurance	Yes
2010-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ENRICHMENT SERVICES PROGRAM, INC WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-04-01	Type of plan entity	Single employer plan
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	7
Insurance contract or identification number 0AY35 Number of Individuals Covered 10 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	1
Insurance contract or identification number 8769 Number of Individuals Covered 14 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided FLEXIBLE SPENDING ACCOUNT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $990 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	2
Insurance contract or identification number ME303 Number of Individuals Covered 113 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $2,250 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER, CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $34,470 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $88 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00622622
Policy instance	3
Insurance contract or identification number 00622622 Number of Individuals Covered 209 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $69,065 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $405,974 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69,065 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5977992
Policy instance	4
Insurance contract or identification number 5977992 Number of Individuals Covered 402 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $16,643 Total amount of fees paid to insurance company USD $4,749 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $113,568 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1387 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Commission paid to Insurance Broker USD $16,643
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000BWRS
Policy instance	5
Insurance contract or identification number G000BWRS Number of Individuals Covered 131 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $25,029 Total amount of fees paid to insurance company USD $6,870 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $115,521 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,796 Amount paid for insurance broker fees 5849 Additional information about fees paid to insurance broker OTHER COMPENSATION, AGENT OR BROKER OF RECORD Insurance broker organization code? 3
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	6
Number of Individuals Covered 2 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Additional information about fees paid to insurance broker 50% FIRST YEAR, 35% THEREAFTER Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000BWRS
Policy instance	9
Insurance contract or identification number G000BWRS Number of Individuals Covered 111 Insurance policy start date 2021-07-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $6,326 Total amount of fees paid to insurance company USD $2,329 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $27,507 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $5,061 Amount paid for insurance broker fees 1194 Insurance broker organization code? 3 Additional information about fees paid to insurance broker OTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000BWRS
Policy instance	8
Insurance contract or identification number G000BWRS Number of Individuals Covered 304 Insurance policy start date 2021-07-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $4,200 Total amount of fees paid to insurance company USD $1,813 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,000 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,200 Insurance broker organization code? 3 Amount paid for insurance broker fees 973 Additional information about fees paid to insurance broker OTHER COMPENSATION
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	7
Insurance contract or identification number 0AY35 Number of Individuals Covered 10 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $986 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,005 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK606642
Policy instance	6
Insurance contract or identification number SOK606642 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $794 Total amount of fees paid to insurance company USD $318 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 318 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $794
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602253
Policy instance	5
Insurance contract or identification number VDT602253 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $3,395 Total amount of fees paid to insurance company USD $1,354 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,636 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 1354 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,395
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK606641
Policy instance	4
Insurance contract or identification number SOK606641 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $911 Total amount of fees paid to insurance company USD $273 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 273 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $911
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000BWRS
Policy instance	10
Insurance contract or identification number G000BWRS Number of Individuals Covered 76 Insurance policy start date 2021-07-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $2,890 Total amount of fees paid to insurance company USD $1,313 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,449 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,890 Amount paid for insurance broker fees 735 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608973
Policy instance	1
Insurance contract or identification number SGM608973 Number of Individuals Covered 335 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $3,615 Total amount of fees paid to insurance company USD $1,084 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 1084 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,615
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000BWRS
Policy instance	11
Insurance contract or identification number G000BWRS Number of Individuals Covered 124 Insurance policy start date 2021-07-01 Insurance policy end date 2022-04-01 Total amount of commissions paid to insurance broker USD $7,469 Total amount of fees paid to insurance company USD $2,541 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT VOLUNTARY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $29,875 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $5,975 Amount paid for insurance broker fees 1308 Additional information about fees paid to insurance broker OTHER COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608974
Policy instance	3
Insurance contract or identification number SGM608974 Insurance policy start date 2020-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $3,338 Total amount of fees paid to insurance company USD $1,335 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1335 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,338
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602254
Policy instance	2
Insurance contract or identification number VDT602254 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $5,863 Total amount of fees paid to insurance company USD $731 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,186 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,197 Amount paid for insurance broker fees 731 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	15
Insurance contract or identification number 8769 Number of Individuals Covered 14 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided FLEXIBLE SPENDING ACCOUNT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $919 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	14
Number of Individuals Covered 2 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Additional information about fees paid to insurance broker 50% FIRST YEAR, 35% THEREAFTER Insurance broker organization code? 3
AMERICAN HERITAGE LIFE (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	13
Insurance contract or identification number ME303 Number of Individuals Covered 119 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $2,248 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER, CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $35,026 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $75 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00622622
Policy instance	12
Insurance contract or identification number 00622622 Number of Individuals Covered 209 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $81,463 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $414,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $81,463 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602253
Policy instance	5
Insurance contract or identification number VDT602253 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $3,395 Total amount of fees paid to insurance company USD $1,354 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,636 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,395 Insurance broker organization code? 3 Amount paid for insurance broker fees 1354 Additional information about fees paid to insurance broker SALES & SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602254
Policy instance	1
Insurance contract or identification number VDT602254 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $5,863 Total amount of fees paid to insurance company USD $731 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,186 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,666 Insurance broker organization code? 3 Amount paid for insurance broker fees 731 Additional information about fees paid to insurance broker SALES & SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK606641
Policy instance	2
Insurance contract or identification number SOK606641 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $911 Total amount of fees paid to insurance company USD $273 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $911 Insurance broker organization code? 3 Amount paid for insurance broker fees 273 Additional information about fees paid to insurance broker SALES & SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608974
Policy instance	3
Insurance contract or identification number SGM608974 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $3,338 Total amount of fees paid to insurance company USD $1,335 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,338 Insurance broker organization code? 3 Amount paid for insurance broker fees 1335 Additional information about fees paid to insurance broker SALES & SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608973
Policy instance	4
Insurance contract or identification number SGM608973 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $3,615 Total amount of fees paid to insurance company USD $1,084 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,615 Insurance broker organization code? 3 Amount paid for insurance broker fees 1084 Additional information about fees paid to insurance broker SALES & SERVICE
AMERICAN HERITAGE LIFE (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	6
Insurance contract or identification number ME303 Number of Individuals Covered 120 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $4,724 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER, CRITICAL ILLNESS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,202 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126 Insurance broker organization code? 3
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	7
Insurance contract or identification number 8769 Number of Individuals Covered 17 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided FLEXIBLE SPENDING ACCOUNT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,040 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	8
Insurance contract or identification number 0AY35 Number of Individuals Covered 10 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,009 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,167 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 Insurance broker organization code? 3
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	9
Number of Individuals Covered 2 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $490 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Additional information about fees paid to insurance broker 50% FIRST YEAR, 35% THEREAFTER Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00622622
Policy instance	10
Insurance contract or identification number 00622622 Number of Individuals Covered 209 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $414,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81,463 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK606642
Policy instance	11
Insurance contract or identification number SOK606642 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $794 Total amount of fees paid to insurance company USD $318 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $794 Insurance broker organization code? 3 Additional information about fees paid to insurance broker SALES & SERVICE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608973
Policy instance	9
Insurance contract or identification number SGM608973 Insurance policy start date 2019-07-01 Insurance policy end date 2020-07-01 Total amount of commissions paid to insurance broker USD $1,683 Total amount of fees paid to insurance company USD $694 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 307 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $1,683
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SGM608974
Policy instance	8
Insurance contract or identification number SGM608974 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $1,827 Total amount of fees paid to insurance company USD $1,057 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,179 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 442 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $1,827
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SOK606641
Policy instance	7
Insurance contract or identification number SOK606641 Insurance policy start date 2019-07-01 Insurance policy end date 2020-07-01 Total amount of commissions paid to insurance broker USD $351 Total amount of fees paid to insurance company USD $142 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,755 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 66 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $351
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602254
Policy instance	6
Insurance contract or identification number VDT602254 Insurance policy start date 2019-07-01 Insurance policy end date 2020-07-01 Total amount of commissions paid to insurance broker USD $637 Total amount of fees paid to insurance company USD $413 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 204 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $637
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00622622
Policy instance	5
Insurance contract or identification number 00622622 Number of Individuals Covered 220 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $54,599 Total amount of fees paid to insurance company USD $5,798 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $311,072 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,599 Insurance broker organization code? 3 Amount paid for insurance broker fees 5798 Additional information about fees paid to insurance broker INCENTIVE COMPENSATION PAID
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	4
Insurance contract or identification number 8769 Number of Individuals Covered 19 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided FLEXIBLE SPENDING ACCOUNT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,790 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	3
Insurance contract or identification number 0AY35 Number of Individuals Covered 11 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,073 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,722 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $436 Insurance broker organization code? 3
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	2
Number of Individuals Covered 3 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $840 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Additional information about fees paid to insurance broker 50% FIRST YEAR, 35% THEREAFTER Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT602253
Policy instance	10
Insurance contract or identification number VDT602253 Insurance policy start date 2019-07-01 Insurance policy end date 2020-07-01 Total amount of commissions paid to insurance broker USD $1,329 Total amount of fees paid to insurance company USD $1,042 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,863 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 446 Additional information about fees paid to insurance broker SALES & SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $1,329
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	1
Insurance contract or identification number ME303 Number of Individuals Covered 138 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $4,367 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $32,529 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $112 Insurance broker organization code? 3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	1
Insurance contract or identification number ME303 Number of Individuals Covered 134 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38,955 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	G0386
Policy instance	7
Insurance contract or identification number G0386 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $3,966 Total amount of fees paid to insurance company USD $257 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $61,360 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,140 Insurance broker organization code? 3 Amount paid for insurance broker fees 257 Additional information about fees paid to insurance broker INCENTIVES
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 14148
Policy instance	6
Insurance contract or identification number 400001000 14148 Number of Individuals Covered 629 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $21,945 Total amount of fees paid to insurance company USD $495 Dental Insurance Welfare Benefit Yes 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 $171,744 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,975 Insurance broker organization code? 3 Amount paid for insurance broker fees 495 Additional information about fees paid to insurance broker BROKER BONUS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	G0385
Policy instance	8
Insurance contract or identification number G0385 Number of Individuals Covered 220 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,901 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100014148
Policy instance	6
Insurance contract or identification number 40000100014148 Number of Individuals Covered 629 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $21,945 Total amount of fees paid to insurance company USD $495 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $171,744 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,970 Amount paid for insurance broker fees 495 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
PARAGON BENEFITS, INC. (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8550
Policy instance	5
Insurance contract or identification number 8550 Number of Individuals Covered 21 Total amount of fees paid to insurance company USD $1,292 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1292 Additional information about fees paid to insurance broker SERVICE Insurance broker organization code? 5 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	4
Insurance contract or identification number 0AY35 Number of Individuals Covered 12 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,119 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CANCER Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,119 Insurance broker organization code? 3
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	3
Number of Individuals Covered 4 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of fees paid to insurance company USD $251 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $718 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Amount paid for insurance broker fees 251 Additional information about fees paid to insurance broker SERVICE FEE Insurance broker organization code? 3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	822723296
Policy instance	2
Insurance contract or identification number 822723296 Number of Individuals Covered 12 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 UNIV LIFE
Policy instance	12
Insurance contract or identification number ME303 UNIV LIFE Number of Individuals Covered 33 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $7,577 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,204 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,361 Insurance broker organization code? 3 Insurance broker name BROOME AGENCY INC
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 TERM LIFE
Policy instance	11
Insurance contract or identification number ME303 TERM LIFE Number of Individuals Covered 14 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,086 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 HOSPITAL
Policy instance	10
Insurance contract or identification number ME303 HOSPITAL Number of Individuals Covered 5 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,550 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	0AY35
Policy instance	9
Insurance contract or identification number 0AY35 Number of Individuals Covered 12 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $1,281 Other welfare benefits provided CANCER Welfare Benefit Premiums Paid to Carrier USD $10,841 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,281 Insurance broker organization code? 3 Insurance broker name SEE ATTACHED
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	8
Number of Individuals Covered 5 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Other welfare benefits provided PREPAID LEGAL Welfare Benefit Premiums Paid to Carrier USD $1,129 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker organization code? 3 Insurance broker name NAVITECH
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303DISABILITY
Policy instance	7
Insurance contract or identification number ME303DISABILITY Number of Individuals Covered 2 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $74 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 CRITICAL
Policy instance	6
Insurance contract or identification number ME303 CRITICAL Number of Individuals Covered 13 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Other welfare benefits provided CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $1,107 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3 Insurance broker name J SMITH LANIER & CO
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	GA6743
Policy instance	1
Insurance contract or identification number GA6743 Number of Individuals Covered 206 Insurance policy start date 2016-07-01 Insurance policy end date 2017-06-30 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,064 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	102695
Policy instance	2
Insurance contract or identification number 102695 Number of Individuals Covered 134 Insurance policy start date 2017-07-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $17,818 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $382,088 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $17,818 Insurance broker organization code? 3 Insurance broker name J SMITH LANIER & CO
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	GA6743
Policy instance	3
Insurance contract or identification number GA6743 Number of Individuals Covered 189 Insurance policy start date 2016-07-01 Insurance policy end date 2017-06-30 Total amount of commissions paid to insurance broker USD $35,410 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $746,640 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,410 Insurance broker organization code? 3 Insurance broker name J SMITH LANIER & CO
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 ACCIDENT
Policy instance	4
Insurance contract or identification number ME303 ACCIDENT Number of Individuals Covered 30 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Other welfare benefits provided ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $6,456 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303 CANCER
Policy instance	5
Insurance contract or identification number ME303 CANCER Number of Individuals Covered 42 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Other welfare benefits provided CANCER Welfare Benefit Premiums Paid to Carrier USD $10,804 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200002960
Policy instance	10
Insurance contract or identification number 40000200002960 Number of Individuals Covered 77 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $3,987 Total amount of fees paid to insurance company USD $181 Other welfare benefits provided VOLUNTARY WI Welfare Benefit Premiums Paid to Carrier USD $26,582 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,987 Amount paid for insurance broker fees 181 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300202826
Policy instance	8
Insurance contract or identification number 40000300202826 Number of Individuals Covered 55 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $1,713 Total amount of fees paid to insurance company USD $75 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,421 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,713 Amount paid for insurance broker fees 75 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010150280
Policy instance	7
Insurance contract or identification number 000010150280 Number of Individuals Covered 195 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $4,237 Total amount of fees paid to insurance company USD $190 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $28,248 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,237 Amount paid for insurance broker fees 190 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	GA6743
Policy instance	6
Insurance contract or identification number GA6743 Number of Individuals Covered 199 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $34,782 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $908,202 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,782 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	1DO22955 00000
Policy instance	5
Insurance contract or identification number 1DO22955 00000 Number of Individuals Covered 155 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $8,685 Total amount of fees paid to insurance company USD $200 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $86,850 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,685 Amount paid for insurance broker fees 200 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	4
Insurance contract or identification number 8769 Number of Individuals Covered 24 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $1,458 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,057 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1458 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 5 Insurance broker name PARAGON BENEFITS INC.
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	3
Number of Individuals Covered 6 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Other welfare benefits provided LEGAL SERVICES Welfare Benefit Premiums Paid to Carrier USD $1,260 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker name NAVITECH, INC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	GA6743
Policy instance	2
Insurance contract or identification number GA6743 Number of Individuals Covered 205 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,267 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	11
Insurance contract or identification number ME303 Number of Individuals Covered 73 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $7,248 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,010 Insurance broker organization code? 3 Insurance broker name WILLIAM HAROLD OWENS
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	OAY35
Policy instance	1
Insurance contract or identification number OAY35 Number of Individuals Covered 13 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $1,467 Other welfare benefits provided CANCER INSURANCE Welfare Benefit Premiums Paid to Carrier USD $11,799 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,467 Insurance broker organization code? 3 Insurance broker name SEE ATTACHED
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100014148
Policy instance	9
Insurance contract or identification number 40000100014148 Number of Individuals Covered 138 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $4,118 Total amount of fees paid to insurance company USD $172 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $27,454 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,118 Amount paid for insurance broker fees 172 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 4 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	GA6743
Policy instance	2
Insurance contract or identification number GA6743 Number of Individuals Covered 208 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,233 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	150280
Policy instance	7
Insurance contract or identification number 150280 Number of Individuals Covered 195 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $4,237 Total amount of fees paid to insurance company USD $190 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,237 Amount paid for insurance broker fees 190 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	GA6743
Policy instance	6
Insurance contract or identification number GA6743 Number of Individuals Covered 197 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $21,589 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $597,721 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,589 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	1DO22955 00000
Policy instance	5
Insurance contract or identification number 1DO22955 00000 Number of Individuals Covered 155 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $8,685 Total amount of fees paid to insurance company USD $200 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $8,685 Amount paid for insurance broker fees 200 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	4
Insurance contract or identification number 8769 Number of Individuals Covered 15 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $1,568 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1568 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 5 Insurance broker name PARAGON BENEFITS INC.
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	3
Number of Individuals Covered 6 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Other welfare benefits provided LEGAL SERVICES Welfare Benefit Premiums Paid to Carrier USD $1,383 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker name NAVITECH, INC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	OAY35
Policy instance	1
Insurance contract or identification number OAY35 Number of Individuals Covered 25 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $1,844 Other welfare benefits provided CANCER INSURANCE Welfare Benefit Premiums Paid to Carrier USD $15,978 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,844 Insurance broker organization code? 3 Insurance broker name SEE ATTACHED
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300202826
Policy instance	8
Insurance contract or identification number 40000300202826 Number of Individuals Covered 55 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $1,713 Total amount of fees paid to insurance company USD $75 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,713 Amount paid for insurance broker fees 75 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 4 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100014148
Policy instance	9
Insurance contract or identification number 40000100014148 Number of Individuals Covered 138 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $4,118 Total amount of fees paid to insurance company USD $172 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,118 Amount paid for insurance broker fees 172 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 4 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000200002960
Policy instance	10
Insurance contract or identification number 40000200002960 Number of Individuals Covered 77 Insurance policy start date 2014-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $3,987 Total amount of fees paid to insurance company USD $181 Other welfare benefits provided VOLUNTARY WI Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $3,987 Amount paid for insurance broker fees 181 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	11
Insurance contract or identification number ME303 Number of Individuals Covered 55 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $402 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $402 Insurance broker organization code? 3 Insurance broker name BENEFIT SPECIALISTS GRP, INC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1037308000
Policy instance	2
Insurance contract or identification number 1037308000 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,339 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $307 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,339 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	3
Number of Individuals Covered 8 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Other welfare benefits provided LEGAL SERVICES Welfare Benefit Premiums Paid to Carrier USD $2,030 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker name NAVITECH, INC
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	4
Insurance contract or identification number 8769 Number of Individuals Covered 25 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of fees paid to insurance company USD $1,590 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1590 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 5 Insurance broker name PARAGON BENEFITS INC.
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	6537740000
Policy instance	7
Insurance contract or identification number 6537740000 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $17,206 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $345,061 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,206 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1037308000
Policy instance	6
Insurance contract or identification number 1037308000 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $55 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number	ME303
Policy instance	8
Insurance contract or identification number ME303 Number of Individuals Covered 55 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,771 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,989 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,920 Insurance broker organization code? 3 Insurance broker name SOUTHERN HARVEST INS. AGCY.
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	GA6743
Policy instance	9
Insurance contract or identification number GA6743 Number of Individuals Covered 136 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	6537740000
Policy instance	10
Insurance contract or identification number 6537740000 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $2,448 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $48,962 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,448 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	150280
Policy instance	11
Insurance contract or identification number 150280 Number of Individuals Covered 174 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,145 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $20,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,145 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	OAY35
Policy instance	1
Insurance contract or identification number OAY35 Number of Individuals Covered 29 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $3,752 Total amount of fees paid to insurance company USD $192 Other welfare benefits provided CANCER INSURANCE Welfare Benefit Premiums Paid to Carrier USD $21,326 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,752 Amount paid for insurance broker fees 192 Additional information about fees paid to insurance broker INCENTIVES, EDUCATION, COMMUNICATION, TRAINING Insurance broker organization code? 3 Insurance broker name SEE ATTACHED
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	1DO22955 00000
Policy instance	5
Insurance contract or identification number 1DO22955 00000 Number of Individuals Covered 139 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $5,678 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $56,780 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,678 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
COVENTRY HEALTH CARE OF GEORGIA (National Association of Insurance Commissioners NAIC id number: 95282 )
Policy contract number	6537740000
Policy instance	2
Insurance contract or identification number 6537740000 Number of Individuals Covered 178 Insurance policy start date 2013-01-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $6,152 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $123,031 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,152 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1037308000
Policy instance	3
Insurance contract or identification number 1037308000 Number of Individuals Covered 295 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,320 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	1DO22955 00000
Policy instance	4
Insurance contract or identification number 1DO22955 00000 Number of Individuals Covered 163 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,591 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $55,912 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,591 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	OAY35
Policy instance	10
Insurance contract or identification number OAY35 Number of Individuals Covered 40 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $5,806 Other welfare benefits provided CANCER INSURANCE Welfare Benefit Premiums Paid to Carrier USD $26,482 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,806 Insurance broker organization code? 3 Insurance broker name SEE ATTACHED
PARAGON BENEFITS INC. SEE BELOW (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	5
Insurance contract or identification number 8769 Number of Individuals Covered 24 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of fees paid to insurance company USD $1,634 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $15,706 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1634 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 5 Insurance broker name PARAGON BENEFITS INC.
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	6
Number of Individuals Covered 12 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Other welfare benefits provided LEGAL SERVICES Welfare Benefit Premiums Paid to Carrier USD $2,608 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker name NAVITECH, INC
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	1037308000
Policy instance	7
Insurance contract or identification number 1037308000 Number of Individuals Covered 108 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,672 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $358,298 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,672 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1037308000
Policy instance	9
Insurance contract or identification number 1037308000 Number of Individuals Covered 89 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $24,022 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $246,800 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,022 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	121291
Policy instance	8
Insurance contract or identification number 121291 Number of Individuals Covered 1 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $29 Other welfare benefits provided LEGAL SERVICES PLAN MEMBERSHIPS Welfare Benefit Premiums Paid to Carrier USD $350 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $3 Insurance broker organization code? 4 Insurance broker name BREAZEALE BUSINESS SERVICE INC.
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	6537740000
Policy instance	1
Insurance contract or identification number 6537740000 Number of Individuals Covered 28 Insurance policy start date 2013-01-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $929 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,583 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $929 Insurance broker organization code? 3 Insurance broker name FLOWERS AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1037308000
Policy instance	7
Insurance contract or identification number 1037308000 Number of Individuals Covered 23 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $55,980 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker organization code? 3 Insurance broker name PARAGON INSURANCE SALES, INC
PARAGON BENEFITS INC. (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number	8769
Policy instance	1
Insurance contract or identification number 8769 Number of Individuals Covered 22 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of fees paid to insurance company USD $2,519 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 2519 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 5 Insurance broker name PARAGON BENEFITS INC.
TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )
Policy contract number	BN2257
Policy instance	2
Insurance contract or identification number BN2257 Number of Individuals Covered 4 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $1,425 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,889 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,425 Insurance broker name NAVITECH, INC.
LEGAL ACCESS PLANS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance	3
Number of Individuals Covered 18 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Other welfare benefits provided LEGAL SERVICES Welfare Benefit Premiums Paid to Carrier USD $8,820 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Insurance broker name MIKE SLADE/NAVITECH
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	1037308000
Policy instance	4
Insurance contract or identification number 1037308000 Number of Individuals Covered 130 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $25,621 Total amount of fees paid to insurance company USD $2,655 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $458,848 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,621 Amount paid for insurance broker fees 2655 Additional information about fees paid to insurance broker INCENTIVES, EDUCATION, COMMUNICATION, TRAINING Insurance broker organization code? 3 Insurance broker name PARAGON INSURANCE SALES, INC.
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	121291
Policy instance	5
Insurance contract or identification number 121291 Number of Individuals Covered 3 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $60 Other welfare benefits provided LEGAL SERVICES PLAN MEMBERSHIPS Welfare Benefit Premiums Paid to Carrier USD $855 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $23 Insurance broker organization code? 4 Insurance broker name EDDIE HARBISON
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00432115
Policy instance	6
Insurance contract or identification number 00432115 Number of Individuals Covered 221 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $20,138 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes 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 $186,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,987 Insurance broker organization code? 3 Insurance broker name PARAGON INSURANCE SALES, INC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	OAY35
Policy instance	8
Insurance contract or identification number OAY35 Number of Individuals Covered 35 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $3,992 Total amount of fees paid to insurance company USD $104 Other welfare benefits provided CANCER INSURANCE Welfare Benefit Premiums Paid to Carrier USD $22,548 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,992 Amount paid for insurance broker fees 104 Additional information about fees paid to insurance broker VARIOUS Insurance broker organization code? 3 Insurance broker name SEE ATTACHED