401k Plan data: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN plan

HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN
Plan identification number	501

HELEN ROSS MCNABB CENTER FLEXIBLE 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) Other welfare benefit cover

401k Sponsoring company profile

HELEN ROSS MCNABB CENTER, INC. has sponsored the creation of one or more 401k plans.

Company Name: HELEN ROSS MCNABB CENTER, INC.

Employer identification number (EIN): 620548914

NAIC Classification: 621420
NAIC Description: Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01 JASON LAY 2024-02-26
501 2021-07-01 JASON LAY 2023-03-01
501 2020-07-01 JASON LAY 2022-02-23
501 2019-07-01 JASON LAY 2020-12-28
501 2018-07-01 JASON LAY 2020-01-06
501 2017-07-01
501 2016-07-01
501 2015-07-01
501 2014-07-01 JASON LAY
501 2013-07-01 JERRY VAGNIER
501 2012-07-01 YOLANDA MONFORT
501 2011-07-01 YOLANDA MONFORT
501 2010-07-01 YOLANDA MONFORT
501 2010-01-01 JON MICHAEL JON MICHAEL 2011-05-24
501 2009-07-01 YOLANDAMONFORT
501 2009-01-01 JONATHAN MICHAEL JONATHAN MICHAEL 2010-07-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-07-01	JASON LAY	2024-02-26
501	2021-07-01	JASON LAY	2023-03-01
501	2020-07-01	JASON LAY	2022-02-23
501	2019-07-01	JASON LAY	2020-12-28
501	2018-07-01	JASON LAY	2020-01-06
501	2017-07-01
501	2016-07-01
501	2015-07-01
501	2014-07-01	JASON LAY
501	2013-07-01	JERRY VAGNIER
501	2012-07-01	YOLANDA MONFORT
501	2011-07-01	YOLANDA MONFORT
501	2010-07-01	YOLANDA MONFORT
501	2010-01-01	JON MICHAEL		JON MICHAEL	2011-05-24
501	2009-07-01	YOLANDAMONFORT
501	2009-01-01	JONATHAN MICHAEL		JONATHAN MICHAEL	2010-07-30

Plan Statistics for HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN

Measure Date Value
2022: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 682
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 659
Number of retired or separated participants receiving benefits 2022-07-01 6
Total of all active and inactive participants 2022-07-01 665
2021: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 628
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 653
Number of retired or separated participants receiving benefits 2021-07-01 5
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 658
2020: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 649
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 640
Number of retired or separated participants receiving benefits 2020-07-01 20
Total of all active and inactive participants 2020-07-01 660
2019: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 631
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 632
Number of retired or separated participants receiving benefits 2019-07-01 17
Total of all active and inactive participants 2019-07-01 649
2018: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 739
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 631
Number of retired or separated participants receiving benefits 2018-07-01 33
Total of all active and inactive participants 2018-07-01 664
2017: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 1,253
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 739
Number of retired or separated participants receiving benefits 2017-07-01 24
Total of all active and inactive participants 2017-07-01 763
2016: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 607
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 1,225
Number of retired or separated participants receiving benefits 2016-07-01 28
Total of all active and inactive participants 2016-07-01 1,253
2015: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 872
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 607
Number of retired or separated participants receiving benefits 2015-07-01 15
Total of all active and inactive participants 2015-07-01 622
2014: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 868
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 872
Number of retired or separated participants receiving benefits 2014-07-01 4
Total of all active and inactive participants 2014-07-01 876
2013: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 699
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 854
Number of retired or separated participants receiving benefits 2013-07-01 14
Total of all active and inactive participants 2013-07-01 868
2012: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 579
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 693
Number of retired or separated participants receiving benefits 2012-07-01 6
Total of all active and inactive participants 2012-07-01 699
2011: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 510
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 571
Number of retired or separated participants receiving benefits 2011-07-01 8
Total of all active and inactive participants 2011-07-01 579
2010: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 426
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 500
Number of retired or separated participants receiving benefits 2010-07-01 10
Total of all active and inactive participants 2010-07-01 510
Total participants, beginning-of-year 2010-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 268
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 268
2009: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 403
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 426
Number of retired or separated participants receiving benefits 2009-07-01 10
Number of other retired or separated participants entitled to future benefits 2009-07-01 1
Total of all active and inactive participants 2009-07-01 437
Total participants, beginning-of-year 2009-01-01 268
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 222
Total of all active and inactive participants 2009-01-01 222

Measure	Date	Value
2022: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	682
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	659
Number of retired or separated participants receiving benefits	2022-07-01	6
Total of all active and inactive participants	2022-07-01	665
2021: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	628
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	653
Number of retired or separated participants receiving benefits	2021-07-01	5
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	658
2020: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	649
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	640
Number of retired or separated participants receiving benefits	2020-07-01	20
Total of all active and inactive participants	2020-07-01	660
2019: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	631
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	632
Number of retired or separated participants receiving benefits	2019-07-01	17
Total of all active and inactive participants	2019-07-01	649
2018: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	739
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	631
Number of retired or separated participants receiving benefits	2018-07-01	33
Total of all active and inactive participants	2018-07-01	664
2017: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	1,253
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	739
Number of retired or separated participants receiving benefits	2017-07-01	24
Total of all active and inactive participants	2017-07-01	763
2016: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	607
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	1,225
Number of retired or separated participants receiving benefits	2016-07-01	28
Total of all active and inactive participants	2016-07-01	1,253
2015: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	872
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	607
Number of retired or separated participants receiving benefits	2015-07-01	15
Total of all active and inactive participants	2015-07-01	622
2014: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	868
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	872
Number of retired or separated participants receiving benefits	2014-07-01	4
Total of all active and inactive participants	2014-07-01	876
2013: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	699
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	854
Number of retired or separated participants receiving benefits	2013-07-01	14
Total of all active and inactive participants	2013-07-01	868
2012: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	579
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	693
Number of retired or separated participants receiving benefits	2012-07-01	6
Total of all active and inactive participants	2012-07-01	699
2011: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	510
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	571
Number of retired or separated participants receiving benefits	2011-07-01	8
Total of all active and inactive participants	2011-07-01	579
2010: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	426
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	500
Number of retired or separated participants receiving benefits	2010-07-01	10
Total of all active and inactive participants	2010-07-01	510
Total participants, beginning-of-year	2010-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	268
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	268
2009: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	403
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	426
Number of retired or separated participants receiving benefits	2009-07-01	10
Number of other retired or separated participants entitled to future benefits	2009-07-01	1
Total of all active and inactive participants	2009-07-01	437
Total participants, beginning-of-year	2009-01-01	268
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	222
Total of all active and inactive participants	2009-01-01	222

Form 5500 Responses for HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN

2022: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HELEN ROSS MCNABB CENTER FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	This submission is the final filing	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	495
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $16,981
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $113,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,981
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	247
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $3,490
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $17,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,490
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1026
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,616
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3616
Insurance broker organization code?	3

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

Policy contract number

000403006672

Policy instance

Insurance contract or identification number	000403006672
Number of Individuals Covered	383
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,499
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,499
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1085
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $44,565
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 $79,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,565
Additional information about fees paid to insurance broker	ACQ/RET
Insurance broker organization code?	3

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	183
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $694
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $3,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $694
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	879
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $27,743
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $184,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,743
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	879
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $18,752
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $125,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,752
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	204
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $16,739
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $111,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,739
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	195
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $14,015
Total amount of fees paid to insurance company	USD $3,063
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $93,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,015
Amount paid for insurance broker fees	3063
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1065
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,673
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3673
Insurance broker organization code?	3

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

Policy contract number

000403006672

Policy instance

Insurance contract or identification number	000403006672
Number of Individuals Covered	387
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,409
Total amount of fees paid to insurance company	USD $305
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,409
Amount paid for insurance broker fees	305
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1109
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $43,075
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 $75,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,075
Additional information about fees paid to insurance broker	ACQ/RET
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	532
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $12,726
Total amount of fees paid to insurance company	USD $2,628
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $84,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,726
Amount paid for insurance broker fees	2628
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	178
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,129
Total amount of fees paid to insurance company	USD $868
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $25,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,129
Amount paid for insurance broker fees	868
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	845
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $17,684
Total amount of fees paid to insurance company	USD $4,243
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,684
Amount paid for insurance broker fees	4243
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	244
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $10,147
Total amount of fees paid to insurance company	USD $1,798
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $51,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,147
Amount paid for insurance broker fees	1798
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	845
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $14,915
Total amount of fees paid to insurance company	USD $3,397
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $99,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,915
Amount paid for insurance broker fees	3397
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1046
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $8,287
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5787
Insurance broker organization code?	3

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

Policy contract number

000403006672

Policy instance

Insurance contract or identification number	000403006672
Number of Individuals Covered	389
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,389
Total amount of fees paid to insurance company	USD $300
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,040
Amount paid for insurance broker fees	300
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1084
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $41,429
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24353
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	517
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $11,053
Total amount of fees paid to insurance company	USD $2,355
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $73,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,189
Amount paid for insurance broker fees	2355
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	864
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $18,505
Total amount of fees paid to insurance company	USD $3,923
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,000
Amount paid for insurance broker fees	3923
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	864
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $14,811
Total amount of fees paid to insurance company	USD $3,135
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $98,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,218
Amount paid for insurance broker fees	3135
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	200
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $12,274
Total amount of fees paid to insurance company	USD $2,752
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $81,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,077
Amount paid for insurance broker fees	2752
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	213
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $9,938
Total amount of fees paid to insurance company	USD $1,927
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $49,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,936
Amount paid for insurance broker fees	1927
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	165
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,597
Total amount of fees paid to insurance company	USD $917
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $22,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,420
Amount paid for insurance broker fees	917
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	125
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $5,367
Total amount of fees paid to insurance company	USD $975
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $26,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,367
Amount paid for insurance broker fees	975
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	183
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $12,541
Total amount of fees paid to insurance company	USD $3,194
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $83,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,541
Amount paid for insurance broker fees	3194
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	1594
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $13,708
Total amount of fees paid to insurance company	USD $2,929
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $91,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,708
Amount paid for insurance broker fees	2929
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	797
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $15,417
Total amount of fees paid to insurance company	USD $4,035
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,417
Amount paid for insurance broker fees	4035
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	480
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,855
Total amount of fees paid to insurance company	USD $2,889
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $72,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,855
Amount paid for insurance broker fees	2889
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1066
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $32,031
Total amount of fees paid to insurance company	USD $7,138
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,031
Amount paid for insurance broker fees	7138
Insurance broker organization code?	3

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

Policy contract number

000403006672

Policy instance

Insurance contract or identification number	000403006672
Number of Individuals Covered	404
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,370
Total amount of fees paid to insurance company	USD $353
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,370
Amount paid for insurance broker fees	353
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1051
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $5,783
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5783
Insurance broker organization code?	3

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	183
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $9,409
Total amount of fees paid to insurance company	USD $1,881
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $47,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,409
Amount paid for insurance broker fees	1881
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000403006672

Policy instance

Insurance contract or identification number	000403006672
Number of Individuals Covered	390
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,127
Total amount of fees paid to insurance company	USD $239
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,127
Amount paid for insurance broker fees	239
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1022
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $6,545
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	6545
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	1064
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $10,014
Total amount of fees paid to insurance company	USD $2,235
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,014
Amount paid for insurance broker fees	2235
Additional information about fees paid to insurance broker	ACQ/RET
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	492
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,988
Total amount of fees paid to insurance company	USD $2,695
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $66,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,988
Amount paid for insurance broker fees	2695
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	129
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $3,928
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $19,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,928
Insurance broker organization code?	3

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	814
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $16,771
Total amount of fees paid to insurance company	USD $4,197
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,771
Amount paid for insurance broker fees	4197
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	1628
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $8,555
Total amount of fees paid to insurance company	USD $2,157
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,555
Amount paid for insurance broker fees	2157
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	183
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $11,177
Total amount of fees paid to insurance company	USD $2,748
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $74,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,177
Amount paid for insurance broker fees	2748
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	162
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $8,086
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $40,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,086
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	228
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $10,660
Total amount of fees paid to insurance company	USD $4,323
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $71,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,660
Amount paid for insurance broker fees	4323
Insurance broker organization code?	3
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

000010230399

Policy instance

Insurance contract or identification number	000010230399
Number of Individuals Covered	144
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,200
Total amount of fees paid to insurance company	USD $3,469
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $61,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,200
Amount paid for insurance broker fees	3469
Insurance broker organization code?	3
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

000010230398

Policy instance

Insurance contract or identification number	000010230398
Number of Individuals Covered	730
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $14,907
Total amount of fees paid to insurance company	USD $5,855
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,907
Amount paid for insurance broker fees	5855
Insurance broker organization code?	3
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

000405004264

Policy instance

Insurance contract or identification number	000405004264
Number of Individuals Covered	94
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,182
Total amount of fees paid to insurance company	USD $1,210
Other welfare benefits provided	CI
Welfare Benefit Premiums Paid to Carrier	USD $17,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,182
Insurance broker organization code?	3
Amount paid for insurance broker fees	1210
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

000010230397

Policy instance

Insurance contract or identification number	000010230397
Number of Individuals Covered	730
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $7,688
Total amount of fees paid to insurance company	USD $3,020
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $51,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,688
Amount paid for insurance broker fees	3020
Insurance broker organization code?	3
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

000404003535

Policy instance

Insurance contract or identification number	000404003535
Number of Individuals Covered	135
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $5,418
Total amount of fees paid to insurance company	USD $2,036
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $29,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,418
Insurance broker organization code?	3
Amount paid for insurance broker fees	2036
Insurance broker name	TRINITY BENEFITS ADVISORS

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	938
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $25,492
Total amount of fees paid to insurance company	USD $6,060
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,492
Amount paid for insurance broker fees	6060
Insurance broker organization code?	3
Insurance broker name	ANDREW MANN

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	918
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $6,897
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	6897
Insurance broker organization code?	3
Insurance broker name	ANDREW MANN

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	903
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $6,677
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	6677
Insurance broker organization code?	3
Insurance broker name	ANDREW MANN

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

Policy contract number

10167976

Policy instance

Insurance contract or identification number	10167976
Number of Individuals Covered	785
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $21,285
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,316
Insurance broker organization code?	3
Insurance broker name	TRINITY BENEFITS ADVISORS

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

Policy contract number

00501287

Policy instance

Insurance contract or identification number	00501287
Number of Individuals Covered	751
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $59,281
Total amount of fees paid to insurance company	USD $14,066
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $490,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,186
Insurance broker organization code?	3
Amount paid for insurance broker fees	14066
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	870
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,500
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2500
Insurance broker organization code?	3
Insurance broker name	ANDREW MANN

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

Policy contract number

10167976

Policy instance

Insurance contract or identification number	10167976
Number of Individuals Covered	754
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $20,093
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,093
Insurance broker organization code?	3
Insurance broker name	STUART R. WORDEN

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

Policy contract number

00501287

Policy instance

Insurance contract or identification number	00501287
Number of Individuals Covered	750
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $61,052
Total amount of fees paid to insurance company	USD $7,326
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $484,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,052
Insurance broker organization code?	3
Amount paid for insurance broker fees	7326
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

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

Policy contract number

10167976

Policy instance

Insurance contract or identification number	10167976
Number of Individuals Covered	620
Insurance policy start date	2013-12-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $17,108
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,108
Insurance broker organization code?	3
Insurance broker name	STUART WORDEN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	747
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $10,548
Total amount of fees paid to insurance company	USD $1,891
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LIFE AND AD & D
Welfare Benefit Premiums Paid to Carrier	USD $94,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,822
Amount paid for insurance broker fees	1891
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

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

Policy contract number

3204908

Policy instance

Insurance contract or identification number	3204908
Number of Individuals Covered	40
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	263
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $13,040
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,520
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	189
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,060
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,030
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	96
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $12,866
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $42,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,433
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	764
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $13,565
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,565
Insurance broker organization code?	3
Insurance broker name	COLE HARRIS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	6
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,359
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $6,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $902
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	596
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $8,169
Total amount of fees paid to insurance company	USD $1,358
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LIFE AND AD & D
Welfare Benefit Premiums Paid to Carrier	USD $67,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,773
Amount paid for insurance broker fees	1358
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SEVICES

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

Policy contract number

10167976

Policy instance

Insurance contract or identification number	10167976
Number of Individuals Covered	530
Insurance policy start date	2012-12-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $8,418
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,418
Insurance broker organization code?	3
Insurance broker name	STUART WORDEN

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

057269S

Policy instance

Insurance contract or identification number	057269S
Number of Individuals Covered	480
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $7,980
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,980
Insurance broker organization code?	3
Insurance broker name	STUART WORDEN

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

Policy contract number

3204908

Policy instance

Insurance contract or identification number	3204908
Number of Individuals Covered	48
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	579
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $9,047
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,047
Insurance broker organization code?	3
Insurance broker name	COLE HARRIS

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	243
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $10,964
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,482
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SEVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	187
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,306
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $653
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SEVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	90
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $11,482
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $38,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,741
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SEVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	59
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $835
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $6,265
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
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

057269S

Policy instance

Insurance contract or identification number	057269S
Number of Individuals Covered	416
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $5,118
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3204908

Policy instance

Insurance contract or identification number	3204908
Number of Individuals Covered	43
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	445
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $6,836
Total amount of fees paid to insurance company	USD $1,125
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LIFE AND AD & D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	116
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $988
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	164
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $9,364
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	164
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $8,946
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	43
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $928
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL CARE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	446
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $7,164
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	404
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,650
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	39
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $7,082
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	69
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $664
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

92820

Policy instance

Insurance contract or identification number	92820
Number of Individuals Covered	406
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $5,083
Total amount of fees paid to insurance company	USD $880
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LIFE AND AD & D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3204908

Policy instance

Insurance contract or identification number	3204908
Number of Individuals Covered	28
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

057269S

Policy instance

Insurance contract or identification number	057269S
Number of Individuals Covered	364
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $5,050
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	100
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $7,248
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1015349

Policy instance

Insurance contract or identification number	1015349
Number of Individuals Covered	32
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $901
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CRITICAL CARE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	HELEN ROSS MCNABB CENTER, INC.
Employer identification number (EIN):	620548914
NAIC Classification:	621420
NAIC Description:	Outpatient Mental Health and Substance Abuse Centers