401k Plan data: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN plan

HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 401k Plan overview

Plan Name	HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN
Plan identification number	501

HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN Benefits

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

401k Sponsoring company profile

HAMILTON HEALTH CARE SYSTEM, INC. has sponsored the creation of one or more 401k plans.

Company Name: HAMILTON HEALTH CARE SYSTEM, INC.

Employer identification number (EIN): 581519913

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KRISTINE GODFREY 2023-10-16
501 2021-01-01 KRISTINE GODFREY 2022-10-13
501 2020-01-01 MARK PITTMAN 2021-10-14
501 2019-01-01 ZIA FENNELL 2020-10-14
501 2018-01-01 RANDALL FOSTER 2019-10-14
501 2018-01-01 RANDALL FOSTER 2019-12-10
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JASON L HOPKINS JOSEPH L MCGUIRE 2013-10-10
501 2011-01-01 JASON L HOPKINS JOSEPH L MCGUIRE 2012-07-27
501 2009-01-01 T STEVEN POUND JOSEPH L MCGUIRE 2010-07-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KRISTINE GODFREY	2023-10-16
501	2021-01-01	KRISTINE GODFREY	2022-10-13
501	2020-01-01	MARK PITTMAN	2021-10-14
501	2019-01-01	ZIA FENNELL	2020-10-14
501	2018-01-01	RANDALL FOSTER	2019-10-14
501	2018-01-01	RANDALL FOSTER	2019-12-10
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	JASON L HOPKINS		JOSEPH L MCGUIRE	2013-10-10
501	2011-01-01	JASON L HOPKINS		JOSEPH L MCGUIRE	2012-07-27
501	2009-01-01	T STEVEN POUND		JOSEPH L MCGUIRE	2010-07-29

Plan Statistics for HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN

401k plan membership statisitcs for HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN

Measure Date Value
2022: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 3,279
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 3,363
Number of retired or separated participants receiving benefits 2022-01-01 42
Total of all active and inactive participants 2022-01-01 3,405
2021: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 3,112
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 3,244
Number of retired or separated participants receiving benefits 2021-01-01 35
Total of all active and inactive participants 2021-01-01 3,279
2020: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 3,583
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 3,083
Number of retired or separated participants receiving benefits 2020-01-01 29
Total of all active and inactive participants 2020-01-01 3,112
2019: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 3,413
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 3,556
Number of retired or separated participants receiving benefits 2019-01-01 27
Total of all active and inactive participants 2019-01-01 3,583
2018: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 3,377
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 3,393
Number of retired or separated participants receiving benefits 2018-01-01 20
Total of all active and inactive participants 2018-01-01 3,413
2017: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,734
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 3,359
Number of retired or separated participants receiving benefits 2017-01-01 13
Total of all active and inactive participants 2017-01-01 3,372
2016: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,987
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,707
Number of retired or separated participants receiving benefits 2016-01-01 27
Total of all active and inactive participants 2016-01-01 2,734
2015: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 2,756
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 2,945
Number of retired or separated participants receiving benefits 2015-01-01 42
Total of all active and inactive participants 2015-01-01 2,987
2014: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,964
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 2,725
Number of retired or separated participants receiving benefits 2014-01-01 31
Total of all active and inactive participants 2014-01-01 2,756
2013: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,852
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,944
Number of retired or separated participants receiving benefits 2013-01-01 20
Total of all active and inactive participants 2013-01-01 1,964
2012: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,853
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,824
Number of retired or separated participants receiving benefits 2012-01-01 28
Total of all active and inactive participants 2012-01-01 1,852
2011: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,290
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,077
Number of retired or separated participants receiving benefits 2011-01-01 26
Total of all active and inactive participants 2011-01-01 1,103
Total participants 2011-01-01 1,103
2009: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,286
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,349
Number of retired or separated participants receiving benefits 2009-01-01 33
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 1,382
Total participants 2009-01-01 0

Measure	Date	Value
2022: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	3,279
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	3,363
Number of retired or separated participants receiving benefits	2022-01-01	42
Total of all active and inactive participants	2022-01-01	3,405
2021: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	3,112
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	3,244
Number of retired or separated participants receiving benefits	2021-01-01	35
Total of all active and inactive participants	2021-01-01	3,279
2020: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	3,583
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	3,083
Number of retired or separated participants receiving benefits	2020-01-01	29
Total of all active and inactive participants	2020-01-01	3,112
2019: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3,413
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	3,556
Number of retired or separated participants receiving benefits	2019-01-01	27
Total of all active and inactive participants	2019-01-01	3,583
2018: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	3,377
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	3,393
Number of retired or separated participants receiving benefits	2018-01-01	20
Total of all active and inactive participants	2018-01-01	3,413
2017: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,734
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	3,359
Number of retired or separated participants receiving benefits	2017-01-01	13
Total of all active and inactive participants	2017-01-01	3,372
2016: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,987
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,707
Number of retired or separated participants receiving benefits	2016-01-01	27
Total of all active and inactive participants	2016-01-01	2,734
2015: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,756
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	2,945
Number of retired or separated participants receiving benefits	2015-01-01	42
Total of all active and inactive participants	2015-01-01	2,987
2014: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,964
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	2,725
Number of retired or separated participants receiving benefits	2014-01-01	31
Total of all active and inactive participants	2014-01-01	2,756
2013: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,852
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,944
Number of retired or separated participants receiving benefits	2013-01-01	20
Total of all active and inactive participants	2013-01-01	1,964
2012: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,853
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,824
Number of retired or separated participants receiving benefits	2012-01-01	28
Total of all active and inactive participants	2012-01-01	1,852
2011: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,290
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,077
Number of retired or separated participants receiving benefits	2011-01-01	26
Total of all active and inactive participants	2011-01-01	1,103
Total participants	2011-01-01	1,103
2009: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,286
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,349
Number of retired or separated participants receiving benefits	2009-01-01	33
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	1,382
Total participants	2009-01-01	0

Form 5500 Responses for HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN

2022: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HAMILTON HEALTH CARE SYSTEM, INC. GROUP BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

VPS325191

Policy instance

Insurance contract or identification number	VPS325191
Number of Individuals Covered	86
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $4,935
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,935
Insurance broker organization code?	3

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

Policy contract number

72363-1

Policy instance

Insurance contract or identification number	72363-1
Number of Individuals Covered	1726
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $105,495
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $421,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105,495
Insurance broker organization code?	3

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	2145
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $13,216
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,216
Insurance broker organization code?	3

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1721
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,963
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $175,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,963
Insurance broker organization code?	3

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1638
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,295
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $223,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,295
Insurance broker organization code?	3

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1721
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,953
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $45,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,953
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

MULTVISIONCONTR

Policy instance

Insurance contract or identification number	MULTVISIONCONTR
Number of Individuals Covered	2647
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,563
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $228,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,573
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542291

Policy instance

Insurance contract or identification number	00542291
Number of Individuals Covered	1398
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,504
Total amount of fees paid to insurance company	USD $4,205
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $78,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,504
Amount paid for insurance broker fees	4205
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	439
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,650
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,650
Insurance broker organization code?	3

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1954
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19,340
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,340
Insurance broker organization code?	3

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1831
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,450
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $309,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,450
Insurance broker organization code?	3

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1780
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,650
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $30,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,650
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

MULTVISIONCONTR

Policy instance

Insurance contract or identification number	MULTVISIONCONTR
Number of Individuals Covered	1739
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,448
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,017
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00566191

Policy instance

Insurance contract or identification number	00566191
Number of Individuals Covered	900
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $130,332
Total amount of fees paid to insurance company	USD $9,686
Other welfare benefits provided	ACCIDENT VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $348,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60,713
Insurance broker organization code?	3
Amount paid for insurance broker fees	3139
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES

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

Policy contract number

VPS325191

Policy instance

Insurance contract or identification number	VPS325191
Number of Individuals Covered	133
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $20,664
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,349
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542291

Policy instance

Insurance contract or identification number	00542291
Number of Individuals Covered	1448
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $44,356
Total amount of fees paid to insurance company	USD $2,709
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,607
Insurance broker organization code?	3
Amount paid for insurance broker fees	2709
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1795
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,524
Total amount of fees paid to insurance company	USD $2,240
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,524
Amount paid for insurance broker fees	2240
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES
Insurance broker organization code?	3

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	576
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,283
Total amount of fees paid to insurance company	USD $1,881
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,283
Amount paid for insurance broker fees	1881
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00566191

Policy instance

Insurance contract or identification number	00566191
Number of Individuals Covered	946
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $167,273
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $266,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $117,088
Insurance broker organization code?	3

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1672
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,934
Total amount of fees paid to insurance company	USD $3,324
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,934
Amount paid for insurance broker fees	3324
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES
Insurance broker organization code?	3

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1795
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,191
Total amount of fees paid to insurance company	USD $467
Other welfare benefits provided	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $18,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,191
Amount paid for insurance broker fees	467
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

MULTVISIONCONTR

Policy instance

Insurance contract or identification number	MULTVISIONCONTR
Number of Individuals Covered	2651
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $31,288
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $221,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,606
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542291

Policy instance

Insurance contract or identification number	00542291
Number of Individuals Covered	1619
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $38,639
Total amount of fees paid to insurance company	USD $5,869
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,639
Amount paid for insurance broker fees	5869
Additional information about fees paid to insurance broker	SALES AND SERVICE FEES
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97466941001

Policy instance

Insurance contract or identification number	97466941001
Number of Individuals Covered	36
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $14
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $14
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542291

Policy instance

Insurance contract or identification number	00542291
Number of Individuals Covered	1576
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $42,122
Total amount of fees paid to insurance company	USD $4,537
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,122
Amount paid for insurance broker fees	4537
Additional information about fees paid to insurance broker	OTHER FEE
Insurance broker organization code?	3

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1039
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,129
Total amount of fees paid to insurance company	USD $517
Other welfare benefits provided	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $34,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,129
Amount paid for insurance broker fees	517
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1886
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,830
Total amount of fees paid to insurance company	USD $3,105
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $216,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,830
Amount paid for insurance broker fees	3105
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	2855
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,146
Total amount of fees paid to insurance company	USD $2,419
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,146
Amount paid for insurance broker fees	2419
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	1912
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,802
Total amount of fees paid to insurance company	USD $2,159
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,802
Amount paid for insurance broker fees	2159
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

99225271001

Policy instance

Insurance contract or identification number	99225271001
Number of Individuals Covered	798
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,541
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,634
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

96827581001

Policy instance

Insurance contract or identification number	96827581001
Number of Individuals Covered	1850
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,363
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,455
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	1846
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,052
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,052
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9922527

Policy instance

Insurance contract or identification number	9922527
Number of Individuals Covered	579
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $-607
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $144,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-607
Insurance broker organization code?	3

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	702
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,739
Total amount of fees paid to insurance company	USD $1,356
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,739
Amount paid for insurance broker fees	1356
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1375
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,573
Total amount of fees paid to insurance company	USD $2,127
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,573
Amount paid for insurance broker fees	2127
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1362
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,937
Total amount of fees paid to insurance company	USD $395
Other welfare benefits provided	MEDICAL IDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $27,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,937
Amount paid for insurance broker fees	395
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542291

Policy instance

Insurance contract or identification number	00542291
Number of Individuals Covered	1477
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $28,401
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,401
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	28
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $157
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $157
Insurance broker organization code?	4

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	2162
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,952
Total amount of fees paid to insurance company	USD $1,935
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,952
Amount paid for insurance broker fees	1935
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	1999
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,226
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,226
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	26
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $39
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	800
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,646
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,646
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9922527

Policy instance

Insurance contract or identification number	9922527
Number of Individuals Covered	455
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,020
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,020
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1865
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $24,700
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $190,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,700
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1516
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,394
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $207,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,394
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1865
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,046
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL IDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $38,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,046
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	457
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,471
Total amount of fees paid to insurance company	USD $2,741
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $145,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,471
Amount paid for insurance broker fees	2741
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	2171
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $17,951
Total amount of fees paid to insurance company	USD $2,904
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,951
Amount paid for insurance broker fees	2904
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1280
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,040
Total amount of fees paid to insurance company	USD $2,980
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,040
Amount paid for insurance broker fees	2980
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1473
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,623
Total amount of fees paid to insurance company	USD $580
Other welfare benefits provided	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $30,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,623
Amount paid for insurance broker fees	580
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	1915
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,522
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,522
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	22
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $144
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $144
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	580
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,017
Total amount of fees paid to insurance company	USD $2,249
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,017
Amount paid for insurance broker fees	2249
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	2185
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $17,461
Total amount of fees paid to insurance company	USD $2,656
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $145,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,461
Amount paid for insurance broker fees	2656
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1201
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,488
Total amount of fees paid to insurance company	USD $2,550
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 $149,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,488
Amount paid for insurance broker fees	2550
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1417
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,483
Total amount of fees paid to insurance company	USD $518
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	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $29,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,483
Amount paid for insurance broker fees	518
Additional information about fees paid to insurance broker	ADDITIONAL FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	2076
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,067
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,067
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	26
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $125
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	29
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $115
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $115
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1353
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $20,895
Total amount of fees paid to insurance company	USD $1,961
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $174,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,895
Amount paid for insurance broker fees	1961
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	572
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,704
Total amount of fees paid to insurance company	USD $1,833
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,704
Amount paid for insurance broker fees	1833
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1092
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,808
Total amount of fees paid to insurance company	USD $1,839
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 $176,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,808
Amount paid for insurance broker fees	1839
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1353
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,071
Total amount of fees paid to insurance company	USD $390
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	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $33,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,071
Amount paid for insurance broker fees	390
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	1915
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,736
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,736
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980146

Policy instance

Insurance contract or identification number	FLX980146
Number of Individuals Covered	1261
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,333
Total amount of fees paid to insurance company	USD $884
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,333
Amount paid for insurance broker fees	884
Additional information about fees paid to insurance broker	SALES AND SERVICE, SUPP. COMMISSION AND OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9682758

Policy instance

Insurance contract or identification number	9682758
Number of Individuals Covered	1824
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,457
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,457
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

OK 980183

Policy instance

Insurance contract or identification number	OK 980183
Number of Individuals Covered	1323
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,899
Total amount of fees paid to insurance company	USD $170
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	MEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $23,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,899
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	SALES AND SERVICE, SUPP. COMMISSION AND OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

LK 980119

Policy instance

Insurance contract or identification number	LK 980119
Number of Individuals Covered	1085
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,297
Total amount of fees paid to insurance company	USD $124
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 $51,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,297
Amount paid for insurance broker fees	124
Additional information about fees paid to insurance broker	SALES AND SERVICE, SUPP. COMMISSION AND OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

FLX980145

Policy instance

Insurance contract or identification number	FLX980145
Number of Individuals Covered	1323
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14,382
Total amount of fees paid to insurance company	USD $823
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,382
Amount paid for insurance broker fees	823
Additional information about fees paid to insurance broker	SALES AND SERVICE, SUPP. COMMISSION AND OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9746694

Policy instance

Insurance contract or identification number	9746694
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $18
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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Company Name:	HAMILTON HEALTH CARE SYSTEM, INC.
Employer identification number (EIN):	581519913
NAIC Classification:	622000
NAIC Description:	Hospitals