401k Plan data: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN plan

LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN
Plan identification number	501

LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

LOCAL GOVERNMENT CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: LOCAL GOVERNMENT CORPORATION

Employer identification number (EIN): 621005866

NAIC Classification: 541519
NAIC Description: Other Computer Related Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-11-01
501 2020-11-01
501 2019-11-01
501 2018-11-01
501 2017-11-01
501 2016-11-01 BRUCE COLLIER
501 2015-11-01 BRUCE COLLIER
501 2014-11-01 BRUCE COLLIER
501 2013-11-01 BRUCE COLLIER
501 2012-11-01 MICKEY WILSON, PRES.
501 2011-11-01 MICKEY WILSON, PRESIDENT
501 2009-11-01 MICKEY WILSON
501 2009-11-01 MICKEY WILSON MICKEY WILSON 2011-05-31

Plan Statistics for LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN

Measure Date Value
2021: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-11-01 152
Total number of active participants reported on line 7a of the Form 5500 2021-11-01 153
Total of all active and inactive participants 2021-11-01 153
Total participants 2021-11-01 153
2020: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-11-01 147
Total number of active participants reported on line 7a of the Form 5500 2020-11-01 152
Total of all active and inactive participants 2020-11-01 152
Total participants 2020-11-01 152
2019: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-11-01 145
Total number of active participants reported on line 7a of the Form 5500 2019-11-01 147
Total of all active and inactive participants 2019-11-01 147
Total participants 2019-11-01 147
2018: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-11-01 144
Total number of active participants reported on line 7a of the Form 5500 2018-11-01 145
Total of all active and inactive participants 2018-11-01 145
Total participants 2018-11-01 145
2017: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-11-01 138
Total number of active participants reported on line 7a of the Form 5500 2017-11-01 144
Total of all active and inactive participants 2017-11-01 144
Total participants 2017-11-01 144
2016: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-11-01 135
Total number of active participants reported on line 7a of the Form 5500 2016-11-01 138
Total of all active and inactive participants 2016-11-01 138
Total participants 2016-11-01 138
2015: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-11-01 126
Total number of active participants reported on line 7a of the Form 5500 2015-11-01 135
Total of all active and inactive participants 2015-11-01 135
Total participants 2015-11-01 0
2014: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-11-01 123
Total number of active participants reported on line 7a of the Form 5500 2014-11-01 126
Total of all active and inactive participants 2014-11-01 126
Total participants 2014-11-01 0
2013: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-11-01 126
Total number of active participants reported on line 7a of the Form 5500 2013-11-01 123
Total of all active and inactive participants 2013-11-01 123
Total participants 2013-11-01 0
2012: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-11-01 126
Total number of active participants reported on line 7a of the Form 5500 2012-11-01 126
Total of all active and inactive participants 2012-11-01 126
Total participants 2012-11-01 126
2011: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-11-01 121
Total number of active participants reported on line 7a of the Form 5500 2011-11-01 126
Total of all active and inactive participants 2011-11-01 126
Total participants 2011-11-01 126
2009: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-11-01 124
Total number of active participants reported on line 7a of the Form 5500 2009-11-01 123
Total of all active and inactive participants 2009-11-01 123
Total participants 2009-11-01 123

Measure	Date	Value
2021: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-11-01	152
Total number of active participants reported on line 7a of the Form 5500	2021-11-01	153
Total of all active and inactive participants	2021-11-01	153
Total participants	2021-11-01	153
2020: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-11-01	147
Total number of active participants reported on line 7a of the Form 5500	2020-11-01	152
Total of all active and inactive participants	2020-11-01	152
Total participants	2020-11-01	152
2019: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-11-01	145
Total number of active participants reported on line 7a of the Form 5500	2019-11-01	147
Total of all active and inactive participants	2019-11-01	147
Total participants	2019-11-01	147
2018: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-11-01	144
Total number of active participants reported on line 7a of the Form 5500	2018-11-01	145
Total of all active and inactive participants	2018-11-01	145
Total participants	2018-11-01	145
2017: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-11-01	138
Total number of active participants reported on line 7a of the Form 5500	2017-11-01	144
Total of all active and inactive participants	2017-11-01	144
Total participants	2017-11-01	144
2016: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-11-01	135
Total number of active participants reported on line 7a of the Form 5500	2016-11-01	138
Total of all active and inactive participants	2016-11-01	138
Total participants	2016-11-01	138
2015: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-11-01	126
Total number of active participants reported on line 7a of the Form 5500	2015-11-01	135
Total of all active and inactive participants	2015-11-01	135
Total participants	2015-11-01	0
2014: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-11-01	123
Total number of active participants reported on line 7a of the Form 5500	2014-11-01	126
Total of all active and inactive participants	2014-11-01	126
Total participants	2014-11-01	0
2013: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-11-01	126
Total number of active participants reported on line 7a of the Form 5500	2013-11-01	123
Total of all active and inactive participants	2013-11-01	123
Total participants	2013-11-01	0
2012: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-11-01	126
Total number of active participants reported on line 7a of the Form 5500	2012-11-01	126
Total of all active and inactive participants	2012-11-01	126
Total participants	2012-11-01	126
2011: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-11-01	121
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	126
Total of all active and inactive participants	2011-11-01	126
Total participants	2011-11-01	126
2009: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-11-01	124
Total number of active participants reported on line 7a of the Form 5500	2009-11-01	123
Total of all active and inactive participants	2009-11-01	123
Total participants	2009-11-01	123

Form 5500 Responses for LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN

2021: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-11-01	Type of plan entity	Single employer plan
2021-11-01	Plan funding arrangement – Insurance	Yes
2021-11-01	Plan benefit arrangement – Insurance	Yes
2020: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-11-01	Type of plan entity	Single employer plan
2020-11-01	Plan funding arrangement – Insurance	Yes
2020-11-01	Plan benefit arrangement – Insurance	Yes
2019: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-11-01	Type of plan entity	Single employer plan
2019-11-01	Plan funding arrangement – Insurance	Yes
2019-11-01	Plan benefit arrangement – Insurance	Yes
2018: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-11-01	Type of plan entity	Single employer plan
2018-11-01	Plan funding arrangement – Insurance	Yes
2018-11-01	Plan benefit arrangement – Insurance	Yes
2017: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-11-01	Type of plan entity	Single employer plan
2017-11-01	Plan funding arrangement – Insurance	Yes
2017-11-01	Plan benefit arrangement – Insurance	Yes
2016: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-11-01	Type of plan entity	Single employer plan
2016-11-01	Plan funding arrangement – Insurance	Yes
2016-11-01	Plan benefit arrangement – Insurance	Yes
2015: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2015 form 5500 responses
2015-11-01	Type of plan entity	Single employer plan
2015-11-01	Plan funding arrangement – Insurance	Yes
2015-11-01	Plan benefit arrangement – Insurance	Yes
2014: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-11-01	Type of plan entity	Single employer plan
2014-11-01	Plan funding arrangement – Insurance	Yes
2014-11-01	Plan benefit arrangement – Insurance	Yes
2013: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-11-01	Type of plan entity	Single employer plan
2013-11-01	Plan funding arrangement – Insurance	Yes
2013-11-01	Plan benefit arrangement – Insurance	Yes
2012: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-11-01	Type of plan entity	Single employer plan
2012-11-01	Plan funding arrangement – Insurance	Yes
2012-11-01	Plan benefit arrangement – Insurance	Yes
2011: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-11-01	Type of plan entity	Single employer plan
2011-11-01	Plan funding arrangement – Insurance	Yes
2011-11-01	Plan benefit arrangement – Insurance	Yes
2009: LOCAL GOVERNMENT CORPORATION FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-11-01	Type of plan entity	Single employer plan
2009-11-01	Plan funding arrangement – Insurance	Yes
2009-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	26
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $447
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $8,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $447
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $762
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $11,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $418
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	152
Insurance policy start date	2021-12-01
Insurance policy end date	2022-12-01
Total amount of commissions paid to insurance broker	USD $4,834
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $32,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,834
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	68
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $2,520
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $24,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,520
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

00626857

Policy instance

Insurance contract or identification number	00626857
Number of Individuals Covered	249
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $15,110
Total amount of fees paid to insurance company	USD $123,080
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,202,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,110
Amount paid for insurance broker fees	123080
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BD7D

Policy instance

Insurance contract or identification number	G000BD7D
Number of Individuals Covered	149
Insurance policy start date	2021-11-01
Insurance policy end date	2022-11-01
Total amount of commissions paid to insurance broker	USD $20,159
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $134,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,159
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	26
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $852
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $8,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $852
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	21
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $766
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $10,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BD7D

Policy instance

Insurance contract or identification number	G000BD7D
Number of Individuals Covered	148
Insurance policy start date	2020-11-01
Insurance policy end date	2021-11-01
Total amount of commissions paid to insurance broker	USD $18,582
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $123,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,582
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	67
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $2,798
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $24,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,798
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

00626857

Policy instance

Insurance contract or identification number	00626857
Number of Individuals Covered	243
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $13,426
Total amount of fees paid to insurance company	USD $116,618
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,094,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,426
Amount paid for insurance broker fees	116618
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	151
Insurance policy start date	2020-12-01
Insurance policy end date	2021-12-01
Total amount of commissions paid to insurance broker	USD $4,682
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $31,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,682
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES & COMMISSIONS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	22
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $790
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $10,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $437
Insurance broker organization code?	3

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

Policy contract number

00626857

Policy instance

Insurance contract or identification number	00626857
Number of Individuals Covered	247
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $21,328
Total amount of fees paid to insurance company	USD $116,921
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,085,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,328
Amount paid for insurance broker fees	116921
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BD7D

Policy instance

Insurance contract or identification number	G000BD7D
Number of Individuals Covered	143
Insurance policy start date	2020-03-01
Insurance policy end date	2020-11-01
Total amount of commissions paid to insurance broker	USD $11,624
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $77,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,624

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	25
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $436
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $7,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $436
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	69
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $2,356
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $23,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,356
Insurance broker organization code?	3

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	157
Insurance policy start date	2019-12-01
Insurance policy end date	2020-12-01
Total amount of commissions paid to insurance broker	USD $4,712
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $31,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,712
Insurance broker organization code?	3

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	149
Insurance policy start date	2018-12-01
Insurance policy end date	2019-12-01
Total amount of commissions paid to insurance broker	USD $4,627
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $30,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,627
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	22
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $864
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $12,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $477
Insurance broker organization code?	3

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

Policy contract number

10227698

Policy instance

Insurance contract or identification number	10227698
Number of Individuals Covered	145
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $5,857
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,857
Insurance broker organization code?	3

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

Policy contract number

10227697

Policy instance

Insurance contract or identification number	10227697
Number of Individuals Covered	145
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $4,929
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,929
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	18
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $2,060
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,060
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	66
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $2,778
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $24,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,778
Insurance broker organization code?	3

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

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	371
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $131,955
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,345,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $131,955
Insurance broker organization code?	3

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

Policy contract number

10227697

Policy instance

Insurance contract or identification number	10227697
Number of Individuals Covered	144
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $5,786
Total amount of fees paid to insurance company	USD $856
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	18
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $450
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10227698

Policy instance

Insurance contract or identification number	10227698
Number of Individuals Covered	144
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $4,667
Total amount of fees paid to insurance company	USD $649
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	69
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,378
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $24,227
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

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	361
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $116,617
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,191,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	126
Insurance policy start date	2017-12-01
Insurance policy end date	2018-12-01
Total amount of commissions paid to insurance broker	USD $4,211
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $28,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

LBT

Policy instance

Insurance contract or identification number	LBT
Number of Individuals Covered	22
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,076
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0259G

Policy instance

Insurance contract or identification number	GVTL0259G
Number of Individuals Covered	75
Insurance policy start date	2014-09-01
Insurance policy end date	2015-09-01
Total amount of commissions paid to insurance broker	USD $3,177
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,177
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	110
Insurance policy start date	2014-12-01
Insurance policy end date	2015-12-01
Total amount of commissions paid to insurance broker	USD $2,559
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,559
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	69
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-30
Total amount of commissions paid to insurance broker	USD $2,597
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $24,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,597
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

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

Policy contract number

00417680

Policy instance

Insurance contract or identification number	00417680
Number of Individuals Covered	110
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $1,804
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,804
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0259G

Policy instance

Insurance contract or identification number	GLUG0259G
Number of Individuals Covered	126
Insurance policy start date	2014-09-01
Insurance policy end date	2015-09-01
Total amount of commissions paid to insurance broker	USD $2,403
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,403
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

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

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	335
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $90,939
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,719,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90,939
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0259G

Policy instance

Insurance contract or identification number	GLTD0259G
Number of Individuals Covered	126
Insurance policy start date	2014-09-01
Insurance policy end date	2015-09-01
Total amount of commissions paid to insurance broker	USD $2,731
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,731
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0259G

Policy instance

Insurance contract or identification number	GLUG0259G
Number of Individuals Covered	123
Insurance policy start date	2013-09-01
Insurance policy end date	2014-09-01
Total amount of commissions paid to insurance broker	USD $2,101
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,101
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

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

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	333
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $84,767
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,613,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,767
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0259G

Policy instance

Insurance contract or identification number	GVTL0259G
Number of Individuals Covered	75
Insurance policy start date	2013-09-01
Insurance policy end date	2014-09-01
Total amount of commissions paid to insurance broker	USD $3,073
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,073
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	115
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $2,197
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,197
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	67
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $2,625
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $25,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,625
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

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

Policy contract number

00417680

Policy instance

Insurance contract or identification number	00417680
Number of Individuals Covered	109
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $1,771
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,771
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0259G

Policy instance

Insurance contract or identification number	GLTD0259G
Number of Individuals Covered	123
Insurance policy start date	2013-09-01
Insurance policy end date	2014-09-01
Total amount of commissions paid to insurance broker	USD $2,366
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,366
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0259G

Policy instance

Insurance contract or identification number	GLUG0259G
Number of Individuals Covered	127
Insurance policy start date	2012-09-01
Insurance policy end date	2013-09-01
Total amount of commissions paid to insurance broker	USD $2,110
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $14,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,110
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES, INC

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

Policy contract number

00417680

Policy instance

Insurance contract or identification number	00417680
Number of Individuals Covered	113
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $1,724
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,724
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES INC

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	119
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,306
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,306
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES INC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

G8630

Policy instance

Insurance contract or identification number	G8630
Number of Individuals Covered	10
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $581
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $4,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $255
Insurance broker organization code?	3
Insurance broker name	DANIEL M SPEER

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	69
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,670
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $26,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,670
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0259G

Policy instance

Insurance contract or identification number	GLTD0259G
Number of Individuals Covered	127
Insurance policy start date	2012-09-01
Insurance policy end date	2013-09-01
Total amount of commissions paid to insurance broker	USD $2,298
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,298
Insurance broker organization code?	3
Insurance broker name	ROGER WITHEROW & ASSOCIATES INC

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

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	341
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $71,044
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,436,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,044
Insurance broker organization code?	3
Insurance broker name	WILLIAM ROGER WITHEROW

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

Policy contract number

00417680

Policy instance

Insurance contract or identification number	00417680
Number of Individuals Covered	111
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $1,717
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,558

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

G8630

Policy instance

Insurance contract or identification number	G8630
Number of Individuals Covered	11
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $702
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,234

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	71
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,343
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $25,987

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0259G

Policy instance

Insurance contract or identification number	GLTD0259G
Number of Individuals Covered	123
Insurance policy start date	2011-09-01
Insurance policy end date	2012-09-01
Total amount of commissions paid to insurance broker	USD $2,780
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,181

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0259G

Policy instance

Insurance contract or identification number	GLUG0259G
Number of Individuals Covered	123
Insurance policy start date	2011-09-01
Insurance policy end date	2012-09-01
Total amount of commissions paid to insurance broker	USD $2,697
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $13,665

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

Policy contract number

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	332
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $50,033
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,394,692

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	116
Insurance policy start date	2011-10-01
Insurance policy end date	2012-10-01
Total amount of commissions paid to insurance broker	USD $2,093
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $13,953

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

Policy contract number

00417680

Policy instance

Insurance contract or identification number	00417680
Number of Individuals Covered	119
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $4,051
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

G8630

Policy instance

Insurance contract or identification number	G8630
Number of Individuals Covered	11
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $702
Other welfare benefits provided	CANCER INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

531037

Policy instance

Insurance contract or identification number	531037
Number of Individuals Covered	121
Insurance policy start date	2009-12-01
Insurance policy end date	2010-12-01
Total amount of commissions paid to insurance broker	USD $2,042
Other welfare benefits provided	GROUP LONG TERM CARE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $13,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0259G

Policy instance

Insurance contract or identification number	GLTD0259G
Number of Individuals Covered	119
Insurance policy start date	2010-09-01
Insurance policy end date	2011-09-01
Total amount of commissions paid to insurance broker	USD $2,335
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0259G

Policy instance

Insurance contract or identification number	GLUG0259G
Number of Individuals Covered	121
Insurance policy start date	2010-09-01
Insurance policy end date	2011-09-01
Total amount of commissions paid to insurance broker	USD $2,337
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $13,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

05221

Policy instance

Insurance contract or identification number	05221
Number of Individuals Covered	70
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $2,400
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $26,710
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

93707

Policy instance

Insurance contract or identification number	93707
Number of Individuals Covered	334
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $51,373
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,295,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	LOCAL GOVERNMENT CORPORATION
Employer identification number (EIN):	621005866
NAIC Classification:	541519
NAIC Description:	Other Computer Related Services