401k Plan data: AVALON HEALTH CARE, LLC plan

AVALON HEALTH CARE, LLC 401k Plan overview

Plan Name	AVALON HEALTH CARE, LLC
Plan identification number	502

AVALON HEALTH CARE, LLC Benefits

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

401k Sponsoring company profile

AVALON HEALTH CARE, LLC has sponsored the creation of one or more 401k plans.

Company Name: AVALON HEALTH CARE, LLC

Employer identification number (EIN): 621720634

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about AVALON HEALTH CARE, LLC

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 2015-02-03

Company Identification Number: L15000020846

Legal Registered Office Address: 4 OFFICE PARK DR

PALM COAST

32137

More information about AVALON HEALTH CARE, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AVALON HEALTH CARE, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-01-01 EMILY WHITCOMB
502 2016-01-01 EMILY WHITCOMB
502 2015-01-01 EMILY WHITCOMB
502 2014-01-01
502 2013-01-01
502 2012-01-01 EMILY WHITCOMB
502 2011-01-01 EMILY WHITCOMB
502 2009-01-01 EMILY WHITCOMB

Plan Statistics for AVALON HEALTH CARE, LLC

401k plan membership statisitcs for AVALON HEALTH CARE, LLC

Measure Date Value
2017: AVALON HEALTH CARE, LLC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 230
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
2016: AVALON HEALTH CARE, LLC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 230
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 230
2015: AVALON HEALTH CARE, LLC 2015 401k membership
Total participants, beginning-of-year 2015-01-01 288
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 285
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 285
2014: AVALON HEALTH CARE, LLC 2014 401k membership
Total participants, beginning-of-year 2014-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 288
Total of all active and inactive participants 2014-01-01 288
2013: AVALON HEALTH CARE, LLC 2013 401k membership
Total participants, beginning-of-year 2013-01-01 272
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 299
Total of all active and inactive participants 2013-01-01 299
2012: AVALON HEALTH CARE, LLC 2012 401k membership
Total participants, beginning-of-year 2012-01-01 321
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 272
Total of all active and inactive participants 2012-01-01 272
2011: AVALON HEALTH CARE, LLC 2011 401k membership
Total participants, beginning-of-year 2011-01-01 338
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 321
Total of all active and inactive participants 2011-01-01 321
2009: AVALON HEALTH CARE, LLC 2009 401k membership
Total participants, beginning-of-year 2009-01-01 295
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 336
Total of all active and inactive participants 2009-01-01 336

Measure	Date	Value
2017: AVALON HEALTH CARE, LLC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	230
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
2016: AVALON HEALTH CARE, LLC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	230
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	230
2015: AVALON HEALTH CARE, LLC 2015 401k membership
Total participants, beginning-of-year	2015-01-01	288
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	285
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	285
2014: AVALON HEALTH CARE, LLC 2014 401k membership
Total participants, beginning-of-year	2014-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	288
Total of all active and inactive participants	2014-01-01	288
2013: AVALON HEALTH CARE, LLC 2013 401k membership
Total participants, beginning-of-year	2013-01-01	272
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	299
Total of all active and inactive participants	2013-01-01	299
2012: AVALON HEALTH CARE, LLC 2012 401k membership
Total participants, beginning-of-year	2012-01-01	321
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	272
Total of all active and inactive participants	2012-01-01	272
2011: AVALON HEALTH CARE, LLC 2011 401k membership
Total participants, beginning-of-year	2011-01-01	338
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	321
Total of all active and inactive participants	2011-01-01	321
2009: AVALON HEALTH CARE, LLC 2009 401k membership
Total participants, beginning-of-year	2009-01-01	295
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	336
Total of all active and inactive participants	2009-01-01	336

Form 5500 Responses for AVALON HEALTH CARE, LLC

2017: AVALON HEALTH CARE, LLC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	Yes
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: AVALON HEALTH CARE, LLC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: AVALON HEALTH CARE, LLC 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: AVALON HEALTH CARE, LLC 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: AVALON HEALTH CARE, LLC 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: AVALON HEALTH CARE, LLC 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: AVALON HEALTH CARE, LLC 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: AVALON HEALTH CARE, LLC 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	251
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,326
Total amount of fees paid to insurance company	USD $7,554
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $161,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,326
Amount paid for insurance broker fees	7554
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	241
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,659
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $994
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0835143

Policy instance

Insurance contract or identification number	0835143
Number of Individuals Covered	285
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $62,550
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,177,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,475
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

15588

Policy instance

Insurance contract or identification number	15588
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $575
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $575
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

15589

Policy instance

Insurance contract or identification number	15589
Number of Individuals Covered	31
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,302
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,302
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

15590

Policy instance

Insurance contract or identification number	15590
Number of Individuals Covered	37
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,780
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,780
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	324
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,316
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $44,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,598
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	244
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,675
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $897
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	164
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,462
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $55,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,283
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

15590

Policy instance

Insurance contract or identification number	15590
Number of Individuals Covered	41
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,015
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,015
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	178
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $15,773
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 $56,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,450
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	246
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,695
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 $6,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $908
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	329
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,128
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
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $43,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,497
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	264
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,384
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 $5,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $829
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	261
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,489
Total amount of fees paid to insurance company	USD $7,545
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,489
Amount paid for insurance broker fees	7545
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

15589

Policy instance

Insurance contract or identification number	15589
Number of Individuals Covered	37
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,523
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,523
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0835143

Policy instance

Insurance contract or identification number	0835143
Number of Individuals Covered	288
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $57,203
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,187,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,414
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	149
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $16,642
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 $59,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,915
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	224
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,673
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 $5,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $896
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

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	299
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,403
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
Other welfare benefits provided	VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $40,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,109
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	254
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,692
Total amount of fees paid to insurance company	USD $6,845
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,692
Amount paid for insurance broker fees	6845
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

LTD 021254

Policy instance

Insurance contract or identification number	LTD 021254
Number of Individuals Covered	6
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $563
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 $4,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $563
Insurance broker organization code?	3
Insurance broker name	VAN METER INSURANCE

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

Policy contract number

GL 026182

Policy instance

Insurance contract or identification number	GL 026182
Number of Individuals Covered	6
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $505
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 $4,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $505
Insurance broker organization code?	3
Insurance broker name	VAN METER INSURANCE

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

Policy contract number

118450

Policy instance

Insurance contract or identification number	118450
Number of Individuals Covered	268
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $40,886
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,886
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER SIMMONS

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

Policy contract number

50007254

Policy instance

Insurance contract or identification number	50007254
Number of Individuals Covered	219
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,604
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $966
Insurance broker organization code?	3
Insurance broker name	VMI ACQUISITION INC.

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

Policy contract number

GL 026182

Policy instance

Insurance contract or identification number	GL 026182
Number of Individuals Covered	7
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $525
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 $4,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $525
Insurance broker organization code?	3
Insurance broker name	VAN METER INSURANCE

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	249
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,682
Total amount of fees paid to insurance company	USD $2,419
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,682
Amount paid for insurance broker fees	2419
Additional information about fees paid to insurance broker	INCEDENTAL COSTS AND BONUSES
Insurance broker organization code?	3
Insurance broker name	VAN METER INS AGENCY

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

Policy contract number

LTD 021254

Policy instance

Insurance contract or identification number	LTD 021254
Number of Individuals Covered	7
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $584
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 $4,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $584
Insurance broker organization code?	3
Insurance broker name	VAN METER INSURANCE

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

Policy contract number

118450

Policy instance

Insurance contract or identification number	118450
Number of Individuals Covered	272
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $70,816
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,816
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER SIMMONS

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

Policy contract number

LTD 021254

Policy instance

Insurance contract or identification number	LTD 021254
Number of Individuals Covered	7
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $575
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 $4,793
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

118450

Policy instance

Insurance contract or identification number	118450
Number of Individuals Covered	321
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $57,121
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 026182

Policy instance

Insurance contract or identification number	GL 026182
Number of Individuals Covered	7
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $518
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 $4,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	307
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,510
Total amount of fees paid to insurance company	USD $3,628
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00264403

Policy instance

Insurance contract or identification number	00264403
Number of Individuals Covered	313
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $14,839
Total amount of fees paid to insurance company	USD $3,229
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $188,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,839
Amount paid for insurance broker fees	3229
Insurance broker organization code?	3
Insurance broker name	BENEFIT SOLUTIONS, INC

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

Policy contract number

118450

Policy instance

Insurance contract or identification number	118450
Number of Individuals Covered	338
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $65,879
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	65879
Insurance broker organization code?	3
Insurance broker name	BENEFIT SOLUTIONS, INC

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

Policy contract number

GL 026182

Policy instance

Insurance contract or identification number	GL 026182
Number of Individuals Covered	8
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $606
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 $5,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $606
Insurance broker organization code?	3
Insurance broker name	BENEFIT SOLUTIONS, INC

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

Policy contract number

LTD 021254

Policy instance

Insurance contract or identification number	LTD 021254
Number of Individuals Covered	8
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $658
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 $5,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $658
Insurance broker organization code?	3
Insurance broker name	BENEFIT SOLUTIONS, INC

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Company Name:	AVALON HEALTH CARE, LLC
Employer identification number (EIN):	621720634
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	2015-02-03
Company Identification Number:	L15000020846
Legal Registered Office Address:	4 OFFICE PARK DR PALM COAST 32137

Plan id#	Filing Submission Date	Name of Administrator
502	2017-01-01	EMILY WHITCOMB
502	2016-01-01	EMILY WHITCOMB
502	2015-01-01	EMILY WHITCOMB
502	2014-01-01
502	2013-01-01
502	2012-01-01	EMILY WHITCOMB
502	2011-01-01	EMILY WHITCOMB
502	2009-01-01	EMILY WHITCOMB