401k Plan data: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN plan

AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

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

Company Name: SERVUS CORPORATION

Employer identification number (EIN): 630971006

NAIC Classification: 541700

Additional information about SERVUS CORPORATION

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 2851704

More information about SERVUS CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2013-11-01 SCOTT ALBRITTON
501 2012-11-01 ASHLEY BAGWELL
501 2011-11-01 SCOTT ALBRITTON
501 2010-11-01 SCOTT ALBRITTON
501 2008-11-01 RENE FORTIN

Plan id#	Filing Submission Date	Name of Administrator
501	2013-11-01	SCOTT ALBRITTON
501	2012-11-01	ASHLEY BAGWELL
501	2011-11-01	SCOTT ALBRITTON
501	2010-11-01	SCOTT ALBRITTON
501	2008-11-01	RENE FORTIN

Plan Statistics for AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2013: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-11-01 104
Total number of active participants reported on line 7a of the Form 5500 2013-11-01 170
Number of retired or separated participants receiving benefits 2013-11-01 1
Number of other retired or separated participants entitled to future benefits 2013-11-01 0
Total of all active and inactive participants 2013-11-01 171
2012: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-11-01 111
Total number of active participants reported on line 7a of the Form 5500 2012-11-01 104
Total of all active and inactive participants 2012-11-01 104
2011: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-11-01 109
Total number of active participants reported on line 7a of the Form 5500 2011-11-01 111
Total of all active and inactive participants 2011-11-01 111
2010: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-11-01 118
Total number of active participants reported on line 7a of the Form 5500 2010-11-01 109
Total of all active and inactive participants 2010-11-01 109
2008: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year 2008-11-01 116
Total number of active participants reported on line 7a of the Form 5500 2008-11-01 121
Total of all active and inactive participants 2008-11-01 121
Total participants 2008-11-01 121

Measure	Date	Value
2013: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-11-01	104
Total number of active participants reported on line 7a of the Form 5500	2013-11-01	170
Number of retired or separated participants receiving benefits	2013-11-01	1
Number of other retired or separated participants entitled to future benefits	2013-11-01	0
Total of all active and inactive participants	2013-11-01	171
2012: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-11-01	111
Total number of active participants reported on line 7a of the Form 5500	2012-11-01	104
Total of all active and inactive participants	2012-11-01	104
2011: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-11-01	109
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	111
Total of all active and inactive participants	2011-11-01	111
2010: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-11-01	118
Total number of active participants reported on line 7a of the Form 5500	2010-11-01	109
Total of all active and inactive participants	2010-11-01	109
2008: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year	2008-11-01	116
Total number of active participants reported on line 7a of the Form 5500	2008-11-01	121
Total of all active and inactive participants	2008-11-01	121
Total participants	2008-11-01	121

Financial Data on AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN

Measure	Date	Value
2011 : AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2011 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-10-31	$69,645
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-10-31	$62,528
Total income from all sources (including contributions)	2011-10-31	$1,250,720
Total of all expenses incurred	2011-10-31	$1,250,720
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-10-31	$1,165,415
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-10-31	$1,250,720
Value of total assets at end of year	2011-10-31	$69,645
Value of total assets at beginning of year	2011-10-31	$62,528
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-10-31	$85,305
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-10-31	No
Was this plan covered by a fidelity bond	2011-10-31	No
If this is an individual account plan, was there a blackout period	2011-10-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-10-31	No
Contributions received from participants	2011-10-31	$505,550
Liabilities. Value of operating payables at end of year	2011-10-31	$6,335
Liabilities. Value of operating payables at beginning of year	2011-10-31	$5,618
Total non interest bearing cash at end of year	2011-10-31	$35,641
Total non interest bearing cash at beginning of year	2011-10-31	$9,702
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-10-31	No
Value of net income/loss	2011-10-31	$0
Value of net assets at end of year (total assets less liabilities)	2011-10-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2011-10-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-10-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-10-31	No
Were any leases to which the plan was party in default or uncollectible	2011-10-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2011-10-31	$264,328
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-10-31	No
Was there a failure to transmit to the plan any participant contributions	2011-10-31	No
Has the plan failed to provide any benefit when due under the plan	2011-10-31	No
Contributions received in cash from employer	2011-10-31	$745,170
Employer contributions (assets) at end of year	2011-10-31	$34,004
Employer contributions (assets) at beginning of year	2011-10-31	$52,826
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-10-31	$901,087
Contract administrator fees	2011-10-31	$85,305
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2011-10-31	No
Liabilities. Value of benefit claims payable at end of year	2011-10-31	$63,310
Liabilities. Value of benefit claims payable at beginning of year	2011-10-31	$56,910
Did the plan have assets held for investment	2011-10-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-10-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-10-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-10-31	No
Opinion of an independent qualified public accountant for this plan	2011-10-31	Unqualified
Accountancy firm name	2011-10-31	R.L. FORTIN, LLC
Accountancy firm EIN	2011-10-31	208420127

Form 5500 Responses for AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN

2013: AMTEC CORPORATION EMPLOYEE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2013-11-01	Plan benefit arrangement – Insurance	Yes
2013-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: AMTEC CORPORATION EMPLOYEE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2012-11-01	Plan benefit arrangement – Insurance	Yes
2012-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: AMTEC CORPORATION EMPLOYEE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2011-11-01	Plan benefit arrangement – Insurance	Yes
2011-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-11-01	Type of plan entity	Single employer plan
2010-11-01	Plan funding arrangement – Insurance	Yes
2010-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-11-01	Plan benefit arrangement – Insurance	Yes
2010-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2008: AMTEC CORPORATION EMPLOYEE WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-11-01	Type of plan entity	Single employer plan
2008-11-01	Submission has been amended	No
2008-11-01	This submission is the final filing	No
2008-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-11-01	Plan is a collectively bargained plan	No
2008-11-01	Plan funding arrangement – Insurance	Yes
2008-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2008-11-01	Plan benefit arrangement – Insurance	Yes
2008-11-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

SOK601679

Policy instance

Insurance contract or identification number	SOK601679
Number of Individuals Covered	93
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $449
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $449
Insurance broker organization code?	3
Insurance broker name	ESTES PEGRAM & ASSOCIATES

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

632365

Policy instance

Insurance contract or identification number	632365
Number of Individuals Covered	61
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $6,005
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,005
Insurance broker organization code?	3
Insurance broker name	ESTES PEGRAM & ASSOCIATES

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

Policy contract number

SOK601677

Policy instance

Insurance contract or identification number	SOK601677
Number of Individuals Covered	93
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $221
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $221
Insurance broker organization code?	3
Insurance broker name	ESTES, PEGRAM & ASSOC

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

Policy contract number

SGM602731

Policy instance

Insurance contract or identification number	SGM602731
Number of Individuals Covered	93
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $2,803
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $21,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,803
Insurance broker organization code?	3
Insurance broker name	ESTES PEGRAM & ASSOCIATES

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

Policy contract number

SGM602730

Policy instance

Insurance contract or identification number	SGM602730
Number of Individuals Covered	93
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $1,766
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $8,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,766
Insurance broker organization code?	3
Insurance broker name	ESTES, PEGRAM & ASSOCIATES

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

Policy contract number

SGD602625

Policy instance

Insurance contract or identification number	SGD602625
Number of Individuals Covered	93
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $3,201
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,201
Insurance broker organization code?	3
Insurance broker name	ESTES, PEGRAM & ASSOCIATES

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS1209

Policy instance

Insurance contract or identification number	VS1209
Number of Individuals Covered	45
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $1,016
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,016
Insurance broker organization code?	3
Insurance broker name	ESTES PEGRAM & ASSOCIATES

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL17956

Policy instance

Insurance contract or identification number	HCL17956
Number of Individuals Covered	63
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $8,826
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,826
Insurance broker organization code?	3
Insurance broker name	ESTES PEGRAM & ASSOCIATES INC.

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS1209

Policy instance

Insurance contract or identification number	VS1209
Number of Individuals Covered	67
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $1,462
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,462
Insurance broker name	ESTES PEGRAM & ASSOCIATES

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

Policy contract number

SOK601679

Policy instance

Insurance contract or identification number	SOK601679
Number of Individuals Covered	93
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $721
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $721
Insurance broker name	ESTES PEGRAM & ASSOCIATES

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL17956

Policy instance

Insurance contract or identification number	HCL17956
Number of Individuals Covered	97
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $11,049
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,049
Insurance broker name	ESTES PEGRAM & ASSOCIATES INC.

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

03499

Policy instance

Insurance contract or identification number	03499
Number of Individuals Covered	104
Insurance policy start date	2012-11-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,431
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,431
Insurance broker name	ESTES PEGRAM HOLLIFIELD & ASSO INC

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

Policy contract number

SGD602625

Policy instance

Insurance contract or identification number	SGD602625
Number of Individuals Covered	93
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $5,464
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,464
Insurance broker name	ESTES, PEGRAM & ASSOCIATES

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

Policy contract number

SGM602730

Policy instance

Insurance contract or identification number	SGM602730
Number of Individuals Covered	93
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,920
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $14,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Insurance broker name	ESTES, PEGRAM & ASSOCIATES

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

Policy contract number

SGM602731

Policy instance

Insurance contract or identification number	SGM602731
Number of Individuals Covered	93
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $4,592
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $35,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,592
Insurance broker name	ESTES PEGRAM & ASSOCIATES

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

Policy contract number

SOK601677

Policy instance

Insurance contract or identification number	SOK601677
Number of Individuals Covered	93
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $375
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $375
Insurance broker name	ESTES, PEGRAM & ASSOC

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

632365

Policy instance

Insurance contract or identification number	632365
Number of Individuals Covered	88
Insurance policy start date	2013-01-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $6,592
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,592
Insurance broker name	ESTES PEGRAM & ASSOCIATES

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

Policy contract number

SOK601677

Policy instance

Insurance contract or identification number	SOK601677
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $413
Total amount of fees paid to insurance company	USD $30
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SGM602731

Policy instance

Insurance contract or identification number	SGM602731
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $4,134
Total amount of fees paid to insurance company	USD $345
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SGM602730

Policy instance

Insurance contract or identification number	SGM602730
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $3,176
Total amount of fees paid to insurance company	USD $232
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SGD602625

Policy instance

Insurance contract or identification number	SGD602625
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $5,968
Total amount of fees paid to insurance company	USD $577
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

03499

Policy instance

Insurance contract or identification number	03499
Number of Individuals Covered	106
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $8,362
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL17956

Policy instance

Insurance contract or identification number	HCL17956
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $11,652
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS1209

Policy instance

Insurance contract or identification number	VS1209
Number of Individuals Covered	84
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $1,469
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SOK601679

Policy instance

Insurance contract or identification number	SOK601679
Number of Individuals Covered	111
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $742
Total amount of fees paid to insurance company	USD $66
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
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

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

03499

Policy instance

Insurance contract or identification number	03499
Number of Individuals Covered	248
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $7,002
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
Welfare Benefit Premiums Paid to Carrier	USD $70,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB125021

Policy instance

Insurance contract or identification number	ETB125021
Number of Individuals Covered	300
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,666
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

00452777

Policy instance

Insurance contract or identification number	00452777
Number of Individuals Covered	137
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $13,590
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS1209

Policy instance

Insurance contract or identification number	VS1209
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 $1,409
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	110
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $10,312
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
Welfare Benefit Premiums Paid to Carrier	USD $103,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SERVUS CORPORATION
Employer identification number (EIN):	630971006
NAIC Classification:	541700

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	2851704