401k Plan data: ACCUMETRIC, LLC GROUP BENEFIT PLAN plan

ACCUMETRIC, LLC GROUP BENEFIT PLAN 401k Plan overview

Plan Name	ACCUMETRIC, LLC GROUP BENEFIT PLAN
Plan identification number	506

ACCUMETRIC, LLC GROUP BENEFIT PLAN Benefits

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

401k Sponsoring company profile

ACCUMETRIC, LLC has sponsored the creation of one or more 401k plans.

Company Name: ACCUMETRIC, LLC

Employer identification number (EIN): 610945483

NAIC Classification: 325500

Additional information about ACCUMETRIC, LLC

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date:

Company Identification Number: 1883905

More information about ACCUMETRIC, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ACCUMETRIC, LLC GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2022-01-01
506 2021-01-01
506 2020-01-01
506 2019-01-01
506 2018-01-01 JOE LEPIRE
506 2017-01-01 CARLOS MORENO
506 2016-01-01 CARLOS MORENO
506 2015-01-01 ALAN HARTLAGE
506 2014-01-01 ALAN HARTLAGE

Plan Statistics for ACCUMETRIC, LLC GROUP BENEFIT PLAN

401k plan membership statisitcs for ACCUMETRIC, LLC GROUP BENEFIT PLAN

Measure Date Value
2022: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 138
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 138
2021: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 123
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 123
2020: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 121
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 121
2019: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 137
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 124
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 124
2018: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 137
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 137
2017: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 125
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 125
2016: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 91
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 109
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 109
2015: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 89
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 91
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 91
2014: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 85
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 89
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 89

Measure	Date	Value
2022: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	138
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	138
2021: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	123
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	123
2020: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	121
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	121
2019: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	137
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	124
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	124
2018: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	137
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	137
2017: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	125
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	125
2016: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	91
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	109
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	109
2015: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	89
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	91
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	91
2014: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	85
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	89
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	89

Form 5500 Responses for ACCUMETRIC, LLC GROUP BENEFIT PLAN

2022: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC 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: ACCUMETRIC, LLC GROUP BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
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

Insurance Providers Used on plan

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

Policy contract number

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $317
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $317
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

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	131
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9
Other welfare benefits provided	AD&D
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
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

L01304

Policy instance

Insurance contract or identification number	L01304
Number of Individuals Covered	225
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $43,964
Total amount of fees paid to insurance company	USD $473
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,451,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,964
Amount paid for insurance broker fees	473
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $11
Other welfare benefits provided	AD&D
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
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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	91
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $170
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $170
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

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	99
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $310
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $310
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

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	138
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $129
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $129
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000024760

Policy instance

Insurance contract or identification number	0000024760
Number of Individuals Covered	39
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,228
Other welfare benefits provided	ACCIDENT, CI AND HI
Welfare Benefit Premiums Paid to Carrier	USD $15,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,228
Insurance broker organization code?	3

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

Policy contract number

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	97
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,230
Total amount of fees paid to insurance company	USD $276
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,230
Amount paid for insurance broker fees	276
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

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	123
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,532
Total amount of fees paid to insurance company	USD $282
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,532
Amount paid for insurance broker fees	282
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

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	65
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,547
Total amount of fees paid to insurance company	USD $136
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,547
Amount paid for insurance broker fees	136
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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	81
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $894
Total amount of fees paid to insurance company	USD $121
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $894
Amount paid for insurance broker fees	121
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

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	39
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $138
Total amount of fees paid to insurance company	USD $108
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $-198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $138
Amount paid for insurance broker fees	108
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

L01304

Policy instance

Insurance contract or identification number	L01304
Number of Individuals Covered	186
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $37,605
Total amount of fees paid to insurance company	USD $2,455
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,260,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,605
Amount paid for insurance broker fees	2455
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	110
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $105
Total amount of fees paid to insurance company	USD $16
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,048
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
Amount paid for insurance broker fees	16
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000024760

Policy instance

Insurance contract or identification number	0000024760
Number of Individuals Covered	48
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,562
Other welfare benefits provided	ACCIDENT, CI AND HI
Welfare Benefit Premiums Paid to Carrier	USD $16,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,562
Insurance broker organization code?	3

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

Policy contract number

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	121
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,928
Total amount of fees paid to insurance company	USD $93
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,928
Amount paid for insurance broker fees	93
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

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	64
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,516
Total amount of fees paid to insurance company	USD $92
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,516
Amount paid for insurance broker fees	92
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

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	86
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,868
Total amount of fees paid to insurance company	USD $99
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,868
Amount paid for insurance broker fees	99
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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	60
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $942
Total amount of fees paid to insurance company	USD $55
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $942
Amount paid for insurance broker fees	55
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	100
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,951
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,951
Insurance broker organization code?	3

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

Policy contract number

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	51
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $384
Total amount of fees paid to insurance company	USD $7
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $384
Amount paid for insurance broker fees	7
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	98
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $43,262
Total amount of fees paid to insurance company	USD $309
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $1,086,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,262
Amount paid for insurance broker fees	309
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	121
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $111
Total amount of fees paid to insurance company	USD $6
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000024760

Policy instance

Insurance contract or identification number	0000024760
Number of Individuals Covered	48
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,051
Other welfare benefits provided	ACCIDENT, CI AND HI
Welfare Benefit Premiums Paid to Carrier	USD $10,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,051
Insurance broker organization code?	3

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

Policy contract number

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	83
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $904
Total amount of fees paid to insurance company	USD $154
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $904
Amount paid for insurance broker fees	154
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	104
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,973
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,973
Insurance broker organization code?	3

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

Policy contract number

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	118
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $171
Total amount of fees paid to insurance company	USD $16
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $171
Amount paid for insurance broker fees	16
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $41,289
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $1,049,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,289
Insurance broker organization code?	3

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

Policy contract number

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $108
Total amount of fees paid to insurance company	USD $19
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108
Amount paid for insurance broker fees	19
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

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	97
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,373
Total amount of fees paid to insurance company	USD $255
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,373
Amount paid for insurance broker fees	255
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

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	120
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,525
Total amount of fees paid to insurance company	USD $240
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,525
Amount paid for insurance broker fees	240
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

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,544
Total amount of fees paid to insurance company	USD $273
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,544
Amount paid for insurance broker fees	273
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

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	137
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,378
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,378
Insurance broker organization code?	3

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

Policy contract number

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	71
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,444
Total amount of fees paid to insurance company	USD $263
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,444
Amount paid for insurance broker fees	263
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

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	84
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,819
Total amount of fees paid to insurance company	USD $183
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,819
Amount paid for insurance broker fees	183
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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	74
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $763
Total amount of fees paid to insurance company	USD $166
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $763
Amount paid for insurance broker fees	166
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	104
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,061
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,061
Insurance broker organization code?	3

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

Policy contract number

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	67
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $20
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123
Amount paid for insurance broker fees	20
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	110
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $39,297
Total amount of fees paid to insurance company	USD $180
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $995,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,297
Amount paid for insurance broker fees	180
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	137
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $96
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96
Insurance broker organization code?	3

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

Policy contract number

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	65
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,464
Total amount of fees paid to insurance company	USD $307
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,464
Amount paid for insurance broker fees	307
Additional information about fees paid to insurance broker	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

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	51
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,566
Total amount of fees paid to insurance company	USD $268
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,566
Amount paid for insurance broker fees	268
Additional information about fees paid to insurance broker	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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	68
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $951
Total amount of fees paid to insurance company	USD $158
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $951
Amount paid for insurance broker fees	158
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	100
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,291
Total amount of fees paid to insurance company	USD $2,000
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,291
Amount paid for insurance broker fees	2000
Additional information about fees paid to insurance broker	BONUS
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

SOK601041

Policy instance

Insurance contract or identification number	SOK601041
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $173
Total amount of fees paid to insurance company	USD $24
Other welfare benefits provided	AD&D
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 $173
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	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

SGM608023

Policy instance

Insurance contract or identification number	SGM608023
Number of Individuals Covered	125
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,823
Total amount of fees paid to insurance company	USD $697
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,823
Amount paid for insurance broker fees	697
Additional information about fees paid to insurance broker	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

SOK605869

Policy instance

Insurance contract or identification number	SOK605869
Number of Individuals Covered	125
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $127
Total amount of fees paid to insurance company	USD $49
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127
Amount paid for insurance broker fees	49
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

775235

Policy instance

Insurance contract or identification number	775235
Number of Individuals Covered	108
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $36,503
Total amount of fees paid to insurance company	USD $158
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $935,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,503
Amount paid for insurance broker fees	158
Additional information about fees paid to insurance broker	BONUS
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

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	46
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,816
Total amount of fees paid to insurance company	USD $433
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,106
Amount paid for insurance broker fees	433
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00235217

Policy instance

Insurance contract or identification number	00235217
Number of Individuals Covered	102
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,751
Total amount of fees paid to insurance company	USD $569
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $888
Amount paid for insurance broker fees	569
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	MEDLINK INC

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

Policy contract number

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	78
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,080
Total amount of fees paid to insurance company	USD $235
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,043
Amount paid for insurance broker fees	235
Additional information about fees paid to insurance broker	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

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	60
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $799
Total amount of fees paid to insurance company	USD $135
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $402
Amount paid for insurance broker fees	135
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

674787

Policy instance

Insurance contract or identification number	674787
Number of Individuals Covered	90
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,848
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $910
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

SOK601401

Policy instance

Insurance contract or identification number	SOK601401
Number of Individuals Covered	46
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $232
Total amount of fees paid to insurance company	USD $37
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,544
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	37
Additional information about fees paid to insurance broker	SALES COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

235217

Policy instance

Insurance contract or identification number	235217
Number of Individuals Covered	151
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $25,077
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $648,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,336
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

SLI600024

Policy instance

Insurance contract or identification number	SLI600024
Number of Individuals Covered	78
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,266
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,266
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

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

Policy contract number

VDT600284

Policy instance

Insurance contract or identification number	VDT600284
Number of Individuals Covered	70
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,477
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,477
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

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

Policy contract number

VDT600283

Policy instance

Insurance contract or identification number	VDT600283
Number of Individuals Covered	52
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $798
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $798
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

674787

Policy instance

Insurance contract or identification number	674787
Number of Individuals Covered	69
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,902
Total amount of fees paid to insurance company	USD $3,257
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,902
Amount paid for insurance broker fees	3257
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

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

Policy contract number

SDK601401

Policy instance

Insurance contract or identification number	SDK601401
Number of Individuals Covered	74
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $329
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Additional information about fees paid to insurance broker	SALES COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

235217

Policy instance

Insurance contract or identification number	235217
Number of Individuals Covered	112
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $25,824
Total amount of fees paid to insurance company	USD $4,369
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $656,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,824
Amount paid for insurance broker fees	4369
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

Policy instance

Number of Individuals Covered	89
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,236
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,236
Insurance broker organization code?	3
Insurance broker name	ASSURED NL INSURANCE AGENCY INC.

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Company Name:	ACCUMETRIC, LLC
Employer identification number (EIN):	610945483
NAIC Classification:	325500

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number:	1883905