401k Plan data: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN plan

MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN
Plan identification number	501

MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

MARIETTA EYE CLINIC has sponsored the creation of one or more 401k plans.

Company Name: MARIETTA EYE CLINIC

Employer identification number (EIN): 581106424

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01
501 2016-07-01 ANISSA JONES ANISSA JONES 2018-04-17
501 2016-07-01 ANISSA JONES 2018-04-17
501 2015-07-01 ANISSA JONES ANISSA JONES 2017-04-05
501 2014-07-01 ANISSA JONES ANISSA JONES 2016-04-14
501 2013-07-01 ANISSA JONES ANISSA JONES 2015-01-29
501 2012-07-01 ANISSA JONES ANISSA JONES 2014-03-06
501 2011-07-01 ANISSA JONES ANISSA JONES 2013-04-11
501 2010-07-01 ANISSA JONES ANISSA JONES 2012-04-11
501 2009-07-01 ANISSA JONES ANISSA JONES 2011-03-08

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01
501	2020-07-01
501	2019-07-01
501	2018-07-01
501	2017-07-01
501	2016-07-01	ANISSA JONES	ANISSA JONES	2018-04-17
501	2016-07-01		ANISSA JONES	2018-04-17
501	2015-07-01	ANISSA JONES	ANISSA JONES	2017-04-05
501	2014-07-01	ANISSA JONES	ANISSA JONES	2016-04-14
501	2013-07-01	ANISSA JONES	ANISSA JONES	2015-01-29
501	2012-07-01	ANISSA JONES	ANISSA JONES	2014-03-06
501	2011-07-01	ANISSA JONES	ANISSA JONES	2013-04-11
501	2010-07-01	ANISSA JONES	ANISSA JONES	2012-04-11
501	2009-07-01	ANISSA JONES	ANISSA JONES	2011-03-08

Plan Statistics for MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN

Measure Date Value
2021: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 195
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 189
Number of retired or separated participants receiving benefits 2021-07-01 3
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 192
2020: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 265
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 249
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 249
2019: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 302
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 227
Number of other retired or separated participants entitled to future benefits 2019-07-01 34
Total of all active and inactive participants 2019-07-01 261
2018: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 293
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 302
Total of all active and inactive participants 2018-07-01 302
2017: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 293
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 293
Total of all active and inactive participants 2017-07-01 293
2016: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 225
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 293
Total of all active and inactive participants 2016-07-01 293
2015: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 216
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 225
Total of all active and inactive participants 2015-07-01 225
2014: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 209
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 216
Total of all active and inactive participants 2014-07-01 216
2013: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 188
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 209
Total of all active and inactive participants 2013-07-01 209
2012: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 172
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 188
Total of all active and inactive participants 2012-07-01 188
2011: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 129
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 172
Total of all active and inactive participants 2011-07-01 172
2010: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 135
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 129
Total of all active and inactive participants 2010-07-01 129
2009: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 162
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 179
Total of all active and inactive participants 2009-07-01 179

Measure	Date	Value
2021: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	195
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	189
Number of retired or separated participants receiving benefits	2021-07-01	3
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	192
2020: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	265
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	249
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	249
2019: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	302
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	227
Number of other retired or separated participants entitled to future benefits	2019-07-01	34
Total of all active and inactive participants	2019-07-01	261
2018: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	293
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	302
Total of all active and inactive participants	2018-07-01	302
2017: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	293
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	293
Total of all active and inactive participants	2017-07-01	293
2016: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	225
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	293
Total of all active and inactive participants	2016-07-01	293
2015: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	216
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	225
Total of all active and inactive participants	2015-07-01	225
2014: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	209
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	216
Total of all active and inactive participants	2014-07-01	216
2013: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	188
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	209
Total of all active and inactive participants	2013-07-01	209
2012: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	172
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	188
Total of all active and inactive participants	2012-07-01	188
2011: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	129
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	172
Total of all active and inactive participants	2011-07-01	172
2010: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	135
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	129
Total of all active and inactive participants	2010-07-01	129
2009: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	162
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	179
Total of all active and inactive participants	2009-07-01	179

Form 5500 Responses for MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN

2021: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	Yes
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2009: MARIETTA EYE CLINIC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	This submission is the final filing	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

908295

Policy instance

Insurance contract or identification number	908295
Number of Individuals Covered	255
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,934
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 $2,626,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	3934
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	244
Insurance policy start date	2021-07-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $15,119
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	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
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 $92,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,119
Insurance broker organization code?	3

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	16
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $395
Total amount of fees paid to insurance company	USD $25
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	CCI, INDEMNITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $103
Insurance broker organization code?	3
Amount paid for insurance broker fees	5
Additional information about fees paid to insurance broker	FEES PAID

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

908295

Policy instance

Insurance contract or identification number	908295
Number of Individuals Covered	265
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	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,347,681
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

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	263
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $48,544
Total amount of fees paid to insurance company	USD $2,350
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
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 $298,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,544
Insurance broker organization code?	3
Amount paid for insurance broker fees	2350
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	15
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,832
Total amount of fees paid to insurance company	USD $312
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	CCI, INDEMNITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $727
Insurance broker organization code?	3
Amount paid for insurance broker fees	37
Additional information about fees paid to insurance broker	FEES PAID

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

908295

Policy instance

Insurance contract or identification number	908295
Number of Individuals Covered	288
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,199,862
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

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	168
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,359
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,359
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	278
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $12,506
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,506
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	281
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $12,707
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,707
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175384

Policy instance

Insurance contract or identification number	000010175384
Number of Individuals Covered	86
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $9,874
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $49,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,874
Insurance broker organization code?	3

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	13
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $470
Total amount of fees paid to insurance company	USD $23
Other welfare benefits provided	CCI
Welfare Benefit Premiums Paid to Carrier	USD $5,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $95
Insurance broker organization code?	3
Amount paid for insurance broker fees	15

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

908295

Policy instance

Insurance contract or identification number	908295
Number of Individuals Covered	302
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $349
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,815,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	349
Additional information about fees paid to insurance broker	BONUS & SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	162
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,407
Total amount of fees paid to insurance company	USD $497
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,407
Insurance broker organization code?	3
Amount paid for insurance broker fees	497
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	259
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $11,476
Total amount of fees paid to insurance company	USD $537
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,476
Insurance broker organization code?	3
Amount paid for insurance broker fees	537
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175384

Policy instance

Insurance contract or identification number	000010175384
Number of Individuals Covered	89
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $9,746
Total amount of fees paid to insurance company	USD $439
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $48,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,746
Insurance broker organization code?	3
Amount paid for insurance broker fees	439
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	258
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $11,428
Total amount of fees paid to insurance company	USD $474
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,428
Insurance broker organization code?	3
Amount paid for insurance broker fees	474
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	15
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $767
Total amount of fees paid to insurance company	USD $113
Other welfare benefits provided	CCI
Welfare Benefit Premiums Paid to Carrier	USD $7,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $102
Amount paid for insurance broker fees	63
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

908295

Policy instance

Insurance contract or identification number	908295
Number of Individuals Covered	293
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $65,869
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,378,022
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

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	148
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,113
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,130
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

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	228
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,926
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,628
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

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	228
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,198
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $45,990
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

000010175384

Policy instance

Insurance contract or identification number	000010175384
Number of Individuals Covered	83
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $8,193
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $40,967
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

000010175384

Policy instance

Insurance contract or identification number	000010175384
Number of Individuals Covered	79
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $7,986
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $39,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,986
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	222
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $10,326
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,326
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6089

Policy instance

Insurance contract or identification number	GA6089
Number of Individuals Covered	161
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $65,606
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,384,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,606
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	9
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $406
Total amount of fees paid to insurance company	USD $20
Other welfare benefits provided	CCI
Welfare Benefit Premiums Paid to Carrier	USD $4,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $145
Insurance broker organization code?	3
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker name	TULLY AND COMPANY INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	138
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $10,521
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,521
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	225
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $6,784
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,784
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6089

Policy instance

Insurance contract or identification number	GA6089
Number of Individuals Covered	150
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $75,240
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,206,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,389
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	127
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $9,783
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,783
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	215
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $10,034
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,034
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

E3762648

Policy instance

Insurance contract or identification number	E3762648
Number of Individuals Covered	12
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,045
Total amount of fees paid to insurance company	USD $260
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CCI
Welfare Benefit Premiums Paid to Carrier	USD $5,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $197
Amount paid for insurance broker fees	162
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	TULLY AND COMPANY INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	216
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $6,600
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,600
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6089

Policy instance

Insurance contract or identification number	GA6089
Number of Individuals Covered	132
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $83,047
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $982,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,714
Insurance broker organization code?	3
Insurance broker name	CARYN E COOK

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D026228

Policy instance

Insurance contract or identification number	00001D026228
Number of Individuals Covered	112
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,497
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,642
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175383

Policy instance

Insurance contract or identification number	000010175383
Number of Individuals Covered	209
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $6,907
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,521
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010175382

Policy instance

Insurance contract or identification number	000010175382
Number of Individuals Covered	209
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $6,058
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,491
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	74
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,071
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,071
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	188
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $10,411
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,411
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	181
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $977
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $977
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	98
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,633
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,633
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6089

Policy instance

Insurance contract or identification number	GA6089
Number of Individuals Covered	117
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $39,715
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $935,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,715
Insurance broker organization code?	3
Insurance broker name	DOMINIUM BENEFITS

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	172
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $9,180
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

1022486000

Policy instance

Insurance contract or identification number	1022486000
Number of Individuals Covered	121
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $48,932
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $933,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	71
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $5,433
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	107
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $6,016
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151911

Policy instance

Insurance contract or identification number	151911
Number of Individuals Covered	172
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $636
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
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

1022486000

Policy instance

Insurance contract or identification number	1022486000
Number of Individuals Covered	129
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $49,591
Total amount of fees paid to insurance company	USD $1,924
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,050,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5301904

Policy instance

Insurance contract or identification number	5301904
Number of Individuals Covered	106
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $11,979
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $120,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	MARIETTA EYE CLINIC
Employer identification number (EIN):	581106424
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)