401k Plan data: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN plan

PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN
Plan identification number	501

PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

PROVIDENCE SCHOOLS OF JACKSONVILLE, INC. has sponsored the creation of one or more 401k plans.

Company Name: PROVIDENCE SCHOOLS OF JACKSONVILLE, INC.

Employer identification number (EIN): 593391416

NAIC Classification: 611000

Additional information about PROVIDENCE SCHOOLS OF JACKSONVILLE, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 1996-05-20

Company Identification Number: N96000002678

Legal Registered Office Address: ONE INDEPENDENT DRIVE

JACKSONVILLE

32202

More information about PROVIDENCE SCHOOLS OF JACKSONVILLE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-09-01 ESTHER WRIGHT 2024-01-25
501 2021-09-01 ESTHER WRIGHT 2023-01-11
501 2020-09-01
501 2019-09-01
501 2018-09-01
501 2017-09-01 ESTHER WRIGHT
501 2016-09-01 ESTHER WRIGHT

Plan Statistics for PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-09-01 194
Total number of active participants reported on line 7a of the Form 5500 2022-09-01 163
Number of retired or separated participants receiving benefits 2022-09-01 0
Number of other retired or separated participants entitled to future benefits 2022-09-01 0
Total of all active and inactive participants 2022-09-01 163
Number of employers contributing to the scheme 2022-09-01 0
2021: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-09-01 199
Total number of active participants reported on line 7a of the Form 5500 2021-09-01 194
Number of retired or separated participants receiving benefits 2021-09-01 0
Number of other retired or separated participants entitled to future benefits 2021-09-01 0
Total of all active and inactive participants 2021-09-01 194
Number of employers contributing to the scheme 2021-09-01 0
2020: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-09-01 189
Total number of active participants reported on line 7a of the Form 5500 2020-09-01 191
Number of retired or separated participants receiving benefits 2020-09-01 0
Number of other retired or separated participants entitled to future benefits 2020-09-01 8
Total of all active and inactive participants 2020-09-01 199
2019: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 187
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 185
Number of retired or separated participants receiving benefits 2019-09-01 0
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 185
2018: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-09-01 180
Total number of active participants reported on line 7a of the Form 5500 2018-09-01 179
Number of retired or separated participants receiving benefits 2018-09-01 0
Number of other retired or separated participants entitled to future benefits 2018-09-01 0
Total of all active and inactive participants 2018-09-01 179
2017: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 176
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 169
Number of retired or separated participants receiving benefits 2017-09-01 0
Number of other retired or separated participants entitled to future benefits 2017-09-01 5
Total of all active and inactive participants 2017-09-01 174
2016: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 174
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 146
Number of retired or separated participants receiving benefits 2016-09-01 0
Number of other retired or separated participants entitled to future benefits 2016-09-01 3
Total of all active and inactive participants 2016-09-01 149

Measure	Date	Value
2022: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-09-01	194
Total number of active participants reported on line 7a of the Form 5500	2022-09-01	163
Number of retired or separated participants receiving benefits	2022-09-01	0
Number of other retired or separated participants entitled to future benefits	2022-09-01	0
Total of all active and inactive participants	2022-09-01	163
Number of employers contributing to the scheme	2022-09-01	0
2021: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-09-01	199
Total number of active participants reported on line 7a of the Form 5500	2021-09-01	194
Number of retired or separated participants receiving benefits	2021-09-01	0
Number of other retired or separated participants entitled to future benefits	2021-09-01	0
Total of all active and inactive participants	2021-09-01	194
Number of employers contributing to the scheme	2021-09-01	0
2020: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-09-01	189
Total number of active participants reported on line 7a of the Form 5500	2020-09-01	191
Number of retired or separated participants receiving benefits	2020-09-01	0
Number of other retired or separated participants entitled to future benefits	2020-09-01	8
Total of all active and inactive participants	2020-09-01	199
2019: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	187
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	185
Number of retired or separated participants receiving benefits	2019-09-01	0
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	185
2018: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-09-01	180
Total number of active participants reported on line 7a of the Form 5500	2018-09-01	179
Number of retired or separated participants receiving benefits	2018-09-01	0
Number of other retired or separated participants entitled to future benefits	2018-09-01	0
Total of all active and inactive participants	2018-09-01	179
2017: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	176
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	169
Number of retired or separated participants receiving benefits	2017-09-01	0
Number of other retired or separated participants entitled to future benefits	2017-09-01	5
Total of all active and inactive participants	2017-09-01	174
2016: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	174
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	146
Number of retired or separated participants receiving benefits	2016-09-01	0
Number of other retired or separated participants entitled to future benefits	2016-09-01	3
Total of all active and inactive participants	2016-09-01	149

Form 5500 Responses for PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN

2022: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-09-01	Type of plan entity	Single employer plan
2022-09-01	Plan funding arrangement – Insurance	Yes
2022-09-01	Plan benefit arrangement – Insurance	Yes
2021: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-09-01	Type of plan entity	Single employer plan
2021-09-01	Plan funding arrangement – Insurance	Yes
2021-09-01	Plan benefit arrangement – Insurance	Yes
2020: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-09-01	Type of plan entity	Single employer plan
2020-09-01	Submission has been amended	No
2020-09-01	This submission is the final filing	No
2020-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-09-01	Plan is a collectively bargained plan	No
2020-09-01	Plan funding arrangement – Insurance	Yes
2020-09-01	Plan benefit arrangement – Insurance	Yes
2019: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	Submission has been amended	No
2019-09-01	This submission is the final filing	No
2019-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-09-01	Plan is a collectively bargained plan	No
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes
2018: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-09-01	Type of plan entity	Single employer plan
2018-09-01	Submission has been amended	No
2018-09-01	This submission is the final filing	No
2018-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-09-01	Plan is a collectively bargained plan	No
2018-09-01	Plan funding arrangement – Insurance	Yes
2018-09-01	Plan benefit arrangement – Insurance	Yes
2017: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	Submission has been amended	No
2017-09-01	This submission is the final filing	No
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-09-01	Plan is a collectively bargained plan	No
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: PROVIDENCE SCHOOLS OF JACKSONVILLE EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	First time form 5500 has been submitted	Yes
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

SGM612360

Policy instance

Insurance contract or identification number	SGM612360
Number of Individuals Covered	163
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $20,416
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS,ACCIDENT,HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $122,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $20,416
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

636824

Policy instance

Insurance contract or identification number	636824
Number of Individuals Covered	163
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $15,773
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $159,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,773
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

636824

Policy instance

Insurance contract or identification number	636824
Number of Individuals Covered	200
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $84,441
Total amount of fees paid to insurance company	USD $75,304
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $609,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,441
Amount paid for insurance broker fees	75304
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

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

Policy contract number

911742

Policy instance

Insurance contract or identification number	911742
Number of Individuals Covered	114
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $72,421
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,521,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	61117
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609271

Policy instance

Insurance contract or identification number	609271
Number of Individuals Covered	145
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $17,100
Total amount of fees paid to insurance company	USD $1,320
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,732
Amount paid for insurance broker fees	1320
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

36447

Policy instance

Insurance contract or identification number	36447
Number of Individuals Covered	117
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $1,733
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,469
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

637205

Policy instance

Insurance contract or identification number	637205
Number of Individuals Covered	27
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $977
Total amount of fees paid to insurance company	USD $53
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $5,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $762
Amount paid for insurance broker fees	53
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GL161111

Policy instance

Insurance contract or identification number	GL161111
Number of Individuals Covered	194
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $8,586
Total amount of fees paid to insurance company	USD $3,255
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $55,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,512
Amount paid for insurance broker fees	3116
Additional information about fees paid to insurance broker	TOTAL ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

637205

Policy instance

Insurance contract or identification number	637205
Number of Individuals Covered	24
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,234
Total amount of fees paid to insurance company	USD $86
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	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,028
Amount paid for insurance broker fees	86
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GL 161111

Policy instance

Insurance contract or identification number	GL 161111
Number of Individuals Covered	194
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $3,700
Total amount of fees paid to insurance company	USD $1,613
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, DEPENDENT LIFE
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 $20,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,700
Amount paid for insurance broker fees	1613
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609271

Policy instance

Insurance contract or identification number	609271
Number of Individuals Covered	161
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $15,261
Total amount of fees paid to insurance company	USD $1,467
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	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 $117,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,739
Amount paid for insurance broker fees	1467
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GL 160931

Policy instance

Insurance contract or identification number	GL 160931
Number of Individuals Covered	69
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $3,863
Total amount of fees paid to insurance company	USD $2,484
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL LIFE AND DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,863
Amount paid for insurance broker fees	2484
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

911742

Policy instance

Insurance contract or identification number	911742
Number of Individuals Covered	268
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $72,378
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 $1,520,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	72378
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 208691

Policy instance

Insurance contract or identification number	VAR 208691
Number of Individuals Covered	60
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $129
Total amount of fees paid to insurance company	USD $77
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	SUPPLEMENTAL AD&D AND DEPENDENT AD&D
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 $860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $129
Amount paid for insurance broker fees	77
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

VPL 303219

Policy instance

Insurance contract or identification number	VPL 303219
Number of Individuals Covered	24
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,064
Total amount of fees paid to insurance company	USD $504
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,064
Amount paid for insurance broker fees	504
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

036447

Policy instance

Insurance contract or identification number	036447
Number of Individuals Covered	113
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,643
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,643
Insurance broker organization code?	3

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

Policy contract number

VPS 328322

Policy instance

Insurance contract or identification number	VPS 328322
Number of Individuals Covered	18
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $511
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	511
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

637205

Policy instance

Insurance contract or identification number	637205
Number of Individuals Covered	19
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $551
Total amount of fees paid to insurance company	USD $68
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	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $410
Amount paid for insurance broker fees	68
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

VPS 328322

Policy instance

Insurance contract or identification number	VPS 328322
Number of Individuals Covered	14
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $202
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	202
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

36447

Policy instance

Insurance contract or identification number	36447
Number of Individuals Covered	111
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $1,474
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,474
Insurance broker organization code?	3

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

Policy contract number

VPL 303219

Policy instance

Insurance contract or identification number	VPL 303219
Number of Individuals Covered	17
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $658
Total amount of fees paid to insurance company	USD $175
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $658
Amount paid for insurance broker fees	175
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 208691

Policy instance

Insurance contract or identification number	VAR 208691
Number of Individuals Covered	59
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $128
Total amount of fees paid to insurance company	USD $34
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	SUPPLEMENTAL AD&D AND DEPENDENT AD&D
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 $850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $128
Amount paid for insurance broker fees	34
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

911742

Policy instance

Insurance contract or identification number	911742
Number of Individuals Covered	252
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $73,806
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 $1,548,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	73806
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GL 160931

Policy instance

Insurance contract or identification number	GL 160931
Number of Individuals Covered	68
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $3,526
Total amount of fees paid to insurance company	USD $1,371
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL LIFE AND DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,526
Amount paid for insurance broker fees	1371
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609271

Policy instance

Insurance contract or identification number	609271
Number of Individuals Covered	158
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $14,860
Total amount of fees paid to insurance company	USD $2,858
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	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 $114,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,431
Amount paid for insurance broker fees	2858
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GL 161111

Policy instance

Insurance contract or identification number	GL 161111
Number of Individuals Covered	186
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $3,491
Total amount of fees paid to insurance company	USD $582
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,491
Amount paid for insurance broker fees	582
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0702233

Policy instance

Insurance contract or identification number	R0702233
Number of Individuals Covered	10
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $631
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $631
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425502 0003

Policy instance

Insurance contract or identification number	425502 0003
Number of Individuals Covered	147
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $549
Total amount of fees paid to insurance company	USD $229
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $549
Amount paid for insurance broker fees	229
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425502 0004

Policy instance

Insurance contract or identification number	425502 0004
Number of Individuals Covered	35
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $134
Total amount of fees paid to insurance company	USD $56
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $134
Amount paid for insurance broker fees	56
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

425502 0001

Policy instance

Insurance contract or identification number	425502 0001
Number of Individuals Covered	54
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $7,394
Total amount of fees paid to insurance company	USD $924
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	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 $73,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,394
Amount paid for insurance broker fees	924
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

425502 0002

Policy instance

Insurance contract or identification number	425502 0002
Number of Individuals Covered	16
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $2,157
Total amount of fees paid to insurance company	USD $270
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,157
Amount paid for insurance broker fees	270
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

911742

Policy instance

Insurance contract or identification number	911742
Number of Individuals Covered	254
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $70,671
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 $1,484,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	70671
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425233

Policy instance

Insurance contract or identification number	425233
Number of Individuals Covered	11
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $770
Total amount of fees paid to insurance company	USD $53
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $770
Amount paid for insurance broker fees	53
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425233 0002

Policy instance

Insurance contract or identification number	425233 0002
Number of Individuals Covered	40
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $1,779
Total amount of fees paid to insurance company	USD $124
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,779
Amount paid for insurance broker fees	124
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

36447

Policy instance

Insurance contract or identification number	36447
Number of Individuals Covered	97
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $1,489
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,489
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425502 0003

Policy instance

Insurance contract or identification number	425502 0003
Number of Individuals Covered	146
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $531
Total amount of fees paid to insurance company	USD $443
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $17,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

425233 0002

Policy instance

Insurance contract or identification number	425233 0002
Number of Individuals Covered	39
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,012
Total amount of fees paid to insurance company	USD $266
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL AD&D, DEPENDENT AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE
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 $11,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

425502 0001

Policy instance

Insurance contract or identification number	425502 0001
Number of Individuals Covered	117
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $7,516
Total amount of fees paid to insurance company	USD $1,879
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	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 $75,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

36447

Policy instance

Insurance contract or identification number	36447
Number of Individuals Covered	201
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $1,879
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

911742

Policy instance

Insurance contract or identification number	911742
Number of Individuals Covered	253
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $75,988
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 $1,369,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0702233

Policy instance

Insurance contract or identification number	R0702233
Number of Individuals Covered	9
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $1,292
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Was this data useful?

If you found the data here useful, PLEASE HELP US. We are a start-up and believe in making information freely available. By linking to us, posting on twitter, facebook and linkedin about us and generally spreading the word, you'll help us to grow. Our vision is to provide high quality data about the activities of all the companies in the world and where possible make it free to use and view. Finding and integrating data from thousands of data sources is time consuming and needs lots of effort. By simply spreading the word about us, you will help us. Please use the share buttons. It will only take a few seconds of your time. Thanks for helping

Information Disclaimer

The information provided on this website is not advice, endorsement or recommendation
The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
You are free to use the information for your own personal research on the understanding to do so is at your own risk.

See full terms and conditions

Company Name:	PROVIDENCE SCHOOLS OF JACKSONVILLE, INC.
Employer identification number (EIN):	593391416
NAIC Classification:	611000

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	1996-05-20
Company Identification Number:	N96000002678
Legal Registered Office Address:	ONE INDEPENDENT DRIVE JACKSONVILLE 32202

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-09-01	ESTHER WRIGHT	2024-01-25
501	2021-09-01	ESTHER WRIGHT	2023-01-11
501	2020-09-01
501	2019-09-01
501	2018-09-01
501	2017-09-01	ESTHER WRIGHT
501	2016-09-01	ESTHER WRIGHT