401k Plan data: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN plan

FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN
Plan identification number	501

FOAM PACKAGING EMPLOYEE HEALTH 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) Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

FOAM PACKAGING, INC. has sponsored the creation of one or more 401k plans.

Company Name: FOAM PACKAGING, INC.

Employer identification number (EIN): 640508940

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-11-01 NATHAN CUMMINS 2023-08-10
501 2020-11-01 NATHAN CUMMINS 2022-07-05
501 2019-11-01 NATHAN CUMMINS 2021-08-04
501 2018-11-01 NATHAN CUMMINS 2020-08-05
501 2017-11-01 DEBRA ISAAC 2019-08-06
501 2016-11-01
501 2015-11-01
501 2014-11-01
501 2013-11-01
501 2012-11-01 RAY ENGLISH
501 2011-11-01 RAY ENGLISH
501 2009-11-01 RAY ENGLISH

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2021-11-01	NATHAN CUMMINS	2023-08-10
501	2020-11-01	NATHAN CUMMINS	2022-07-05
501	2019-11-01	NATHAN CUMMINS	2021-08-04
501	2018-11-01	NATHAN CUMMINS	2020-08-05
501	2017-11-01	DEBRA ISAAC	2019-08-06
501	2016-11-01
501	2015-11-01
501	2014-11-01
501	2013-11-01
501	2012-11-01	RAY ENGLISH
501	2011-11-01	RAY ENGLISH
501	2009-11-01	RAY ENGLISH

Plan Statistics for FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN

401k plan membership statisitcs for FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN

Measure Date Value
2021: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-11-01 107
Total number of active participants reported on line 7a of the Form 5500 2021-11-01 104
Number of retired or separated participants receiving benefits 2021-11-01 0
Number of other retired or separated participants entitled to future benefits 2021-11-01 0
Total of all active and inactive participants 2021-11-01 104
2020: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-11-01 132
Total number of active participants reported on line 7a of the Form 5500 2020-11-01 107
Number of retired or separated participants receiving benefits 2020-11-01 0
Number of other retired or separated participants entitled to future benefits 2020-11-01 0
Total of all active and inactive participants 2020-11-01 107
2019: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-11-01 118
Total number of active participants reported on line 7a of the Form 5500 2019-11-01 132
Number of retired or separated participants receiving benefits 2019-11-01 0
Number of other retired or separated participants entitled to future benefits 2019-11-01 0
Total of all active and inactive participants 2019-11-01 132
2018: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-11-01 126
Total number of active participants reported on line 7a of the Form 5500 2018-11-01 118
Number of retired or separated participants receiving benefits 2018-11-01 0
Number of other retired or separated participants entitled to future benefits 2018-11-01 0
Total of all active and inactive participants 2018-11-01 118
2017: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-11-01 157
Total number of active participants reported on line 7a of the Form 5500 2017-11-01 126
Total of all active and inactive participants 2017-11-01 126
2016: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-11-01 193
Total number of active participants reported on line 7a of the Form 5500 2016-11-01 157
Total of all active and inactive participants 2016-11-01 157
2015: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-11-01 116
Total number of active participants reported on line 7a of the Form 5500 2015-11-01 193
Total of all active and inactive participants 2015-11-01 193
2014: FOAM PACKAGING EMPLOYEE HEALTH 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 2014-11-01 116
Total of all active and inactive participants 2014-11-01 116
2013: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-11-01 110
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
2012: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-11-01 115
Total number of active participants reported on line 7a of the Form 5500 2012-11-01 110
Total of all active and inactive participants 2012-11-01 110
2011: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-11-01 117
Total number of active participants reported on line 7a of the Form 5500 2011-11-01 115
Number of retired or separated participants receiving benefits 2011-11-01 0
Number of other retired or separated participants entitled to future benefits 2011-11-01 0
Total of all active and inactive participants 2011-11-01 115
2009: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-11-01 110
Total number of active participants reported on line 7a of the Form 5500 2009-11-01 116
Number of retired or separated participants receiving benefits 2009-11-01 0
Number of other retired or separated participants entitled to future benefits 2009-11-01 0
Total of all active and inactive participants 2009-11-01 116

Measure	Date	Value
2021: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-11-01	107
Total number of active participants reported on line 7a of the Form 5500	2021-11-01	104
Number of retired or separated participants receiving benefits	2021-11-01	0
Number of other retired or separated participants entitled to future benefits	2021-11-01	0
Total of all active and inactive participants	2021-11-01	104
2020: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-11-01	132
Total number of active participants reported on line 7a of the Form 5500	2020-11-01	107
Number of retired or separated participants receiving benefits	2020-11-01	0
Number of other retired or separated participants entitled to future benefits	2020-11-01	0
Total of all active and inactive participants	2020-11-01	107
2019: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-11-01	118
Total number of active participants reported on line 7a of the Form 5500	2019-11-01	132
Number of retired or separated participants receiving benefits	2019-11-01	0
Number of other retired or separated participants entitled to future benefits	2019-11-01	0
Total of all active and inactive participants	2019-11-01	132
2018: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-11-01	126
Total number of active participants reported on line 7a of the Form 5500	2018-11-01	118
Number of retired or separated participants receiving benefits	2018-11-01	0
Number of other retired or separated participants entitled to future benefits	2018-11-01	0
Total of all active and inactive participants	2018-11-01	118
2017: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-11-01	157
Total number of active participants reported on line 7a of the Form 5500	2017-11-01	126
Total of all active and inactive participants	2017-11-01	126
2016: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-11-01	193
Total number of active participants reported on line 7a of the Form 5500	2016-11-01	157
Total of all active and inactive participants	2016-11-01	157
2015: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-11-01	116
Total number of active participants reported on line 7a of the Form 5500	2015-11-01	193
Total of all active and inactive participants	2015-11-01	193
2014: FOAM PACKAGING EMPLOYEE HEALTH 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	116
Total of all active and inactive participants	2014-11-01	116
2013: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-11-01	110
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
2012: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-11-01	115
Total number of active participants reported on line 7a of the Form 5500	2012-11-01	110
Total of all active and inactive participants	2012-11-01	110
2011: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-11-01	117
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	115
Number of retired or separated participants receiving benefits	2011-11-01	0
Number of other retired or separated participants entitled to future benefits	2011-11-01	0
Total of all active and inactive participants	2011-11-01	115
2009: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-11-01	110
Total number of active participants reported on line 7a of the Form 5500	2009-11-01	116
Number of retired or separated participants receiving benefits	2009-11-01	0
Number of other retired or separated participants entitled to future benefits	2009-11-01	0
Total of all active and inactive participants	2009-11-01	116

Financial Data on FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN

Measure	Date	Value
2014 : FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2014 401k financial data
Total income from all sources	2014-10-31	$1,110,355
Expenses. Total of all expenses incurred	2014-10-31	$1,136,876
Benefits paid (including direct rollovers)	2014-10-31	$1,081,584
Total plan assets at end of year	2014-10-31	$0
Total plan assets at beginning of year	2014-10-31	$26,521
Net income (gross income less expenses)	2014-10-31	$-26,521
Net plan assets at end of year (total assets less liabilities)	2014-10-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2014-10-31	$26,521
Total contributions received or receivable from employer(s)	2014-10-31	$1,110,355
Expenses. Administrative service providers (salaries,fees and commissions)	2014-10-31	$55,292
2013 : FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2013 401k financial data
Total income from all sources	2013-10-31	$836,691
Expenses. Total of all expenses incurred	2013-10-31	$829,755
Benefits paid (including direct rollovers)	2013-10-31	$741,167
Total plan assets at end of year	2013-10-31	$26,521
Total plan assets at beginning of year	2013-10-31	$19,585
Other income received	2013-10-31	$343,924
Net income (gross income less expenses)	2013-10-31	$6,936
Net plan assets at end of year (total assets less liabilities)	2013-10-31	$26,521
Net plan assets at beginning of year (total assets less liabilities)	2013-10-31	$19,585
Total contributions received or receivable from employer(s)	2013-10-31	$492,767
Expenses. Administrative service providers (salaries,fees and commissions)	2013-10-31	$88,588
2012 : FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2012 401k financial data
Total income from all sources	2012-10-31	$741,083
Expenses. Total of all expenses incurred	2012-10-31	$767,415
Benefits paid (including direct rollovers)	2012-10-31	$672,052
Total plan assets at end of year	2012-10-31	$19,585
Total plan assets at beginning of year	2012-10-31	$45,917
Net income (gross income less expenses)	2012-10-31	$-26,332
Net plan assets at end of year (total assets less liabilities)	2012-10-31	$19,585
Net plan assets at beginning of year (total assets less liabilities)	2012-10-31	$45,917
Total contributions received or receivable from employer(s)	2012-10-31	$741,083
Expenses. Administrative service providers (salaries,fees and commissions)	2012-10-31	$95,363
2011 : FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2011 401k financial data
Total income from all sources	2011-10-31	$739,147
Expenses. Total of all expenses incurred	2011-10-31	$720,683
Benefits paid (including direct rollovers)	2011-10-31	$625,028
Total plan assets at end of year	2011-10-31	$45,917
Total plan assets at beginning of year	2011-10-31	$27,453
Net income (gross income less expenses)	2011-10-31	$18,464
Net plan assets at end of year (total assets less liabilities)	2011-10-31	$45,917
Net plan assets at beginning of year (total assets less liabilities)	2011-10-31	$27,453
Total contributions received or receivable from employer(s)	2011-10-31	$739,147
Expenses. Administrative service providers (salaries,fees and commissions)	2011-10-31	$95,655

Form 5500 Responses for FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN

2021: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH 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: FOAM PACKAGING EMPLOYEE HEALTH BENEFIT PLAN 2009 form 5500 responses
2009-11-01	Type of plan entity	Single employer plan
2009-11-01	This submission is the final filing	No
2009-11-01	Plan funding arrangement – Insurance	Yes
2009-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

GULF GUARANTY EMPLOYEE BENEFIT SERVICES, INC (National Association of Insurance Commissioners NAIC id number: 77976 )

Policy contract number

1269

Policy instance

Insurance contract or identification number	1269
Number of Individuals Covered	102
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $7,718
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,718
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609347

Policy instance

Insurance contract or identification number	609347
Number of Individuals Covered	66
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $4,954
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,954
Insurance broker organization code?	3

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

Policy contract number

609346

Policy instance

Insurance contract or identification number	609346
Number of Individuals Covered	84
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $4,307
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,307
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

08F0955

Policy instance

Insurance contract or identification number	08F0955
Number of Individuals Covered	104
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $39,667
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $586,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,667
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

08F0955

Policy instance

Insurance contract or identification number	08F0955
Number of Individuals Covered	107
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $24,618
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $511,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,618
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609347

Policy instance

Insurance contract or identification number	609347
Number of Individuals Covered	67
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $6,004
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,273
Insurance broker organization code?	3

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

Policy contract number

609346

Policy instance

Insurance contract or identification number	609346
Number of Individuals Covered	84
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $3,521
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,845
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609347

Policy instance

Insurance contract or identification number	609347
Number of Individuals Covered	72
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $6,852
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,091
Insurance broker organization code?	3

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

Policy contract number

609346

Policy instance

Insurance contract or identification number	609346
Number of Individuals Covered	87
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $3,490
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,175
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

08F0955

Policy instance

Insurance contract or identification number	08F0955
Number of Individuals Covered	132
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $30,762
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $640,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,762
Insurance broker organization code?	3

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

Policy contract number

00543632

Policy instance

Insurance contract or identification number	00543632
Number of Individuals Covered	80
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $9,685
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,685
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

0018938

Policy instance

Insurance contract or identification number	0018938
Number of Individuals Covered	118
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $23,483
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 $23,483
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

0018938

Policy instance

Insurance contract or identification number	0018938
Number of Individuals Covered	126
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $25,175
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
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

00543632

Policy instance

Insurance contract or identification number	00543632
Number of Individuals Covered	81
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $12,931
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0903616

Policy instance

Insurance contract or identification number	0903616
Number of Individuals Covered	115
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $55,966
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 $1,119,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,966
Insurance broker organization code?	3
Insurance broker name	HUB INT'L MIDWEST LIMITED (MS)

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

240625

Policy instance

Insurance contract or identification number	240625
Number of Individuals Covered	116
Insurance policy start date	2014-11-04
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,544
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,068
Insurance broker organization code?	3
Insurance broker name	FOX-EVERETT, INC.

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

FOAM1213

Policy instance

Insurance contract or identification number	FOAM1213
Number of Individuals Covered	68
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $4,358
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,975
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

FOAM1213

Policy instance

Insurance contract or identification number	FOAM1213
Number of Individuals Covered	62
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,315
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 $10,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $605
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

SPECTERA, INC. (National Association of Insurance Commissioners NAIC id number: 74950 )

Policy contract number

DD03VOLU

Policy instance

Insurance contract or identification number	DD03VOLU
Number of Individuals Covered	44
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $120
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 $570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63
Insurance broker organization code?	3
Insurance broker name	SCOTT BINGHAM

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

FOAM1213

Policy instance

Insurance contract or identification number	FOAM1213
Number of Individuals Covered	65
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $973
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 $8,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $973
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

FOAM1213

Policy instance

Insurance contract or identification number	FOAM1213
Number of Individuals Covered	75
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $3,386
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,386
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

644775

Policy instance

Insurance contract or identification number	644775
Number of Individuals Covered	119
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $46,940
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 $1,012,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,940
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

8136

Policy instance

Insurance contract or identification number	8136
Number of Individuals Covered	24
Insurance policy start date	2013-11-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $278
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $278
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

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

Policy contract number

000010148936 00

Policy instance

Insurance contract or identification number	000010148936 00
Number of Individuals Covered	104
Insurance policy start date	2013-11-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

8136

Policy instance

Insurance contract or identification number	8136
Number of Individuals Covered	123
Insurance policy start date	2013-12-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $3,595
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,595
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

7509-MS120-C

Policy instance

Insurance contract or identification number	7509-MS120-C
Number of Individuals Covered	110
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $24,298
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 $161,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,298
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

045315

Policy instance

Insurance contract or identification number	045315
Number of Individuals Covered	109
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,589
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 $2,589
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

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

Policy contract number

000010148936 00

Policy instance

Insurance contract or identification number	000010148936 00
Number of Individuals Covered	104
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $1,397
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,397
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

008136

Policy instance

Insurance contract or identification number	008136
Insurance policy start date	2012-11-01
Insurance policy end date	2013-05-01
Total amount of commissions paid to insurance broker	USD $1,286
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,286
Insurance broker organization code?	3
Insurance broker name	SCOTT A BINGHAM

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

Policy instance

Number of Individuals Covered	0
Insurance policy start date	2013-05-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $1,499
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,499
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

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

Policy contract number

000010148937 00

Policy instance

Insurance contract or identification number	000010148937 00
Number of Individuals Covered	98
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,170
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,170
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

SPECTERA, INC. (National Association of Insurance Commissioners NAIC id number: 74950 )

Policy contract number

DD03VOLU

Policy instance

Insurance contract or identification number	DD03VOLU
Number of Individuals Covered	42
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
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 $6,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $738
Insurance broker organization code?	3
Insurance broker name	ROSS & YERGER INSURANCE, INC.

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

Policy contract number

000010148936 00

Policy instance

Insurance contract or identification number	000010148936 00
Number of Individuals Covered	115
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $1,967
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LONDON LIFE REINSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 76694 )

Policy contract number

8506-MS100-L

Policy instance

Insurance contract or identification number	8506-MS100-L
Number of Individuals Covered	115
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $25,682
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 $139,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SPECTERA, INC. (National Association of Insurance Commissioners NAIC id number: 74950 )

Policy contract number

DD03VOLU

Policy instance

Insurance contract or identification number	DD03VOLU
Number of Individuals Covered	47
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $1,451
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 $6,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

045315

Policy instance

Insurance contract or identification number	045315
Number of Individuals Covered	115
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,809
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

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

008136

Policy instance

Insurance contract or identification number	008136
Number of Individuals Covered	0
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,476
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,821
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

000010148937 00

Policy instance

Insurance contract or identification number	000010148937 00
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 $2,870
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

008136

Policy instance

Insurance contract or identification number	008136
Number of Individuals Covered	61
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $3,516
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,844
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

G000969J

Policy instance

Insurance contract or identification number	G000969J
Number of Individuals Covered	117
Insurance policy start date	2010-11-01
Insurance policy end date	2011-11-01
Total amount of commissions paid to insurance broker	USD $2,316
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SPECTERA, INC. (National Association of Insurance Commissioners NAIC id number: 74950 )

Policy contract number

DD03VOLU

Policy instance

Insurance contract or identification number	DD03VOLU
Number of Individuals Covered	40
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $1,222
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 $5,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008136

Policy instance

Insurance contract or identification number	008136
Number of Individuals Covered	117
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $2,611
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LONDON LIFE REINSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 76694 )

Policy contract number

8506-MS100-L

Policy instance

Insurance contract or identification number	8506-MS100-L
Number of Individuals Covered	116
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $25,538
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 $321,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

045315

Policy instance

Insurance contract or identification number	045315
Number of Individuals Covered	116
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $2,799
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

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Company Name:	FOAM PACKAGING, INC.
Employer identification number (EIN):	640508940
NAIC Classification:	339900