LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN
Plan identification number	510

LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

LARKIN COMMUNITY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name:	LARKIN COMMUNITY HOSPITAL
Employer identification number (EIN):	650729921
NAIC Classification:	622000
NAIC Description:	Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2022-07-01	MAGGIE CAMPOS	2024-01-29	MAGGIE CAMPOS	2024-01-29
510	2021-07-01
510	2020-07-01
510	2019-07-01
510	2018-07-01
510	2017-07-01	MAGGIE CAMPOS
510	2016-07-01	CAROLINA PENA
510	2015-07-01	CAROLINA PENA
510	2014-07-01	CAROLINA PENA
510	2013-07-01	CAROLINA PENA
510	2012-07-01	DESHIRE PENA
510	2011-07-01	DESHIRE PENA
510	2010-01-01	DESHIRE PENA
510	2009-01-01	DESHIRE PENA
510	2008-01-01	DESHIRE PENA
510	2007-01-01	DESHIRE PENA
510	2006-01-01	DESHIRE PENA
510	2005-01-01	DESHIRE PENA

Plan Statistics for LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN

401k plan membership statisitcs for LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN

Measure	Date	Value
2022: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	1,583
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	1,463
Number of retired or separated participants receiving benefits	2022-07-01	2
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	1,465
2021: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	830
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	970
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	970
2020: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	1,361
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	830
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	830
2019: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	1,371
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	1,361
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	1,361
2018: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	1,434
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	1,371
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	1,371
2017: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	1,543
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	1,434
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	1,434
2016: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	979
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	1,543
Number of retired or separated participants receiving benefits	2016-07-01	0
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	1,543
2015: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	686
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	979
Number of retired or separated participants receiving benefits	2015-07-01	0
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	979
2014: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	613
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	686
Number of retired or separated participants receiving benefits	2014-07-01	0
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	686
2013: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	570
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	613
Number of retired or separated participants receiving benefits	2013-07-01	0
Number of other retired or separated participants entitled to future benefits	2013-07-01	0
Total of all active and inactive participants	2013-07-01	613
2012: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	340
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	570
Number of retired or separated participants receiving benefits	2012-07-01	0
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	570
2011: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	305
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	340
Number of retired or separated participants receiving benefits	2011-07-01	0
Number of other retired or separated participants entitled to future benefits	2011-07-01	0
Total of all active and inactive participants	2011-07-01	340
2010: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	328
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	305
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	305
2009: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	307
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	328
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	328
2008: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	334
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	307
Number of retired or separated participants receiving benefits	2008-01-01	0
Number of other retired or separated participants entitled to future benefits	2008-01-01	0
Total of all active and inactive participants	2008-01-01	307
2007: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	334
Number of retired or separated participants receiving benefits	2007-01-01	0
Number of other retired or separated participants entitled to future benefits	2007-01-01	0
Total of all active and inactive participants	2007-01-01	334
2006: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year	2006-01-01	312
Total number of active participants reported on line 7a of the Form 5500	2006-01-01	265
Number of retired or separated participants receiving benefits	2006-01-01	0
Number of other retired or separated participants entitled to future benefits	2006-01-01	0
Total of all active and inactive participants	2006-01-01	265
2005: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year	2005-01-01	312
Total number of active participants reported on line 7a of the Form 5500	2005-01-01	312
Number of retired or separated participants receiving benefits	2005-01-01	0
Number of other retired or separated participants entitled to future benefits	2005-01-01	0
Total of all active and inactive participants	2005-01-01	312

Form 5500 Responses for LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN

2022: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2021: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Submission has been amended	No
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Submission has been amended	No
2018-07-01	This submission is the final filing	No
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-07-01	Plan is a collectively bargained plan	No
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Submission has been amended	No
2017-07-01	This submission is the final filing	No
2017-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-07-01	Plan is a collectively bargained plan	No
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2008: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Submission has been amended	No
2008-01-01	This submission is the final filing	No
2008-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-01-01	Plan is a collectively bargained plan	No
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes
2007: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	No
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2006: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	Submission has been amended	No
2006-01-01	This submission is the final filing	No
2006-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-01-01	Plan is a collectively bargained plan	No
2006-01-01	Plan funding arrangement – Insurance	Yes
2006-01-01	Plan benefit arrangement – Insurance	Yes
2005: LARKIN COMMUNITY HOSPITAL EMPLOYEE WELFARE BENEFITS PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	First time form 5500 has been submitted	Yes
2005-01-01	Submission has been amended	No
2005-01-01	This submission is the final filing	No
2005-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-01-01	Plan is a collectively bargained plan	No
2005-01-01	Plan funding arrangement – Insurance	Yes
2005-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	4
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 145 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $7,022 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $75,213 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,566 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0BTNW
Policy instance	9
Insurance contract or identification number GVTL0BTNW Number of Individuals Covered 77 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $2,194 Total amount of fees paid to insurance company USD $0 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 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 $21,089 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,289 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	1
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 998 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $9,042 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT 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 $97,123 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,886 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AX6W
Policy instance	2
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 96 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $5,272 Total amount of fees paid to insurance company USD $0 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 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 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 $56,688 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,771 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AX6W
Policy instance	3
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 118 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $3,161 Total amount of fees paid to insurance company USD $0 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 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 $33,980 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,631 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3345094
Policy instance	5
Insurance contract or identification number 3345094 Number of Individuals Covered 1287 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $33,095 Total amount of fees paid to insurance company USD $25,000 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 Yes Vision Insurance Welfare Benefit Yes 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 $1,807,081 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,130 Amount paid for insurance broker fees 25000 Additional information about fees paid to insurance broker SERVICE/GEN. AGENT FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0BTNW
Policy instance	6
Insurance contract or identification number GLUG0BTNW Number of Individuals Covered 714 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $8,210 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM 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 $71,548 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,477 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0BTNW
Policy instance	7
Insurance contract or identification number GUC 0BTNW Number of Individuals Covered 57 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $2,977 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $31,175 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,503 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0BTNW
Policy instance	8
Insurance contract or identification number GUPR0BTNW Number of Individuals Covered 35 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $1,915 Total amount of fees paid to insurance company USD $0 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 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 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 $19,494 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $978 Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	839354
Policy instance	7
Insurance contract or identification number 839354 Number of Individuals Covered 645 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $6,443 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes 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 $61,508 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,443 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	1
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 970 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $8,799 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided 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 $87,986 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,799 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AX6W
Policy instance	2
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 82 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $4,990 Total amount of fees paid to insurance company USD $0 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 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 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 $49,898 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,990 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AX6W
Policy instance	3
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 86 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $2,825 Total amount of fees paid to insurance company USD $0 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 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 $28,247 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,825 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	4
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 164 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $8,492 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $84,918 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,492 Insurance broker organization code? 3
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	839354
Policy instance	5
Insurance contract or identification number 839354 Number of Individuals Covered 278 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $5,905 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit Yes 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 $56,033 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,905 Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	839354
Policy instance	6
Insurance contract or identification number 839354 Number of Individuals Covered 602 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $39,715 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit Yes 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 $380,113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,715 Insurance broker organization code? 3
HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 )
Policy contract number	839354
Policy instance	8
Insurance contract or identification number 839354 Number of Individuals Covered 997 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $278,970 Total amount of fees paid to insurance company USD $0 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 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 $5,372,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $278,970 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AX6W
Policy instance	2
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 103 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $5,680 Total amount of fees paid to insurance company USD $0 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 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 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 $56,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,680 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AX6W
Policy instance	3
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 80 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $2,571 Total amount of fees paid to insurance company USD $0 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 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 $25,707 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,571 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	4
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 168 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $9,553 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $95,533 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,553 Insurance broker organization code? 3
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	839354
Policy instance	5
Insurance contract or identification number 839354 Number of Individuals Covered 270 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $4,576 Total amount of fees paid to insurance company USD $828 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 No Dental Insurance Welfare Benefit Yes 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 $53,110 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,576 Amount paid for insurance broker fees 828 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	839354
Policy instance	6
Insurance contract or identification number 839354 Number of Individuals Covered 561 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $27,079 Total amount of fees paid to insurance company USD $1,672 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 No Dental Insurance Welfare Benefit Yes 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 $321,784 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,079 Amount paid for insurance broker fees 1672 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	839354
Policy instance	7
Insurance contract or identification number 839354 Number of Individuals Covered 609 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $5,016 Total amount of fees paid to insurance company USD $400 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes 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 $53,951 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,016 Amount paid for insurance broker fees 400 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 )
Policy contract number	839354
Policy instance	8
Insurance contract or identification number 839354 Number of Individuals Covered 995 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $201,758 Total amount of fees paid to insurance company USD $20,000 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 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 $4,333,512 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $201,758 Amount paid for insurance broker fees 20000 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	1
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 830 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $8,166 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided 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 $81,662 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,166 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	1
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 1361 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $11,771 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided 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 $117,707 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,771 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AX6W
Policy instance	2
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 214 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $11,809 Total amount of fees paid to insurance company USD $0 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 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 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 $118,085 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,809 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AX6W
Policy instance	3
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 149 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $4,598 Total amount of fees paid to insurance company USD $0 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 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 $45,984 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,598 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	4
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 274 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $13,171 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $131,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,171 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0835466-SL
Policy instance	5
Insurance contract or identification number 0835466-SL Number of Individuals Covered 1034 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 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 No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes 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 $738,188 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	835466
Policy instance	1
Insurance contract or identification number 835466 Number of Individuals Covered 1152 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 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 Yes Vision Insurance Welfare Benefit Yes 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 $646,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	2
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 1371 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $11,771 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided 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 $118,018 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,771 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUPR0AX6W
Policy instance	3
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 250 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $12,461 Total amount of fees paid to insurance company USD $0 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 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 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 $124,749 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,461 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AX6W
Policy instance	4
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 183 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $5,740 Total amount of fees paid to insurance company USD $0 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 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 $57,542 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,740 Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	5
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 325 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $14,855 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $148,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,855 Insurance broker organization code? 3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	6
Insurance contract or identification number TM05984020 Number of Individuals Covered 597 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $9,357 Total amount of fees paid to insurance company USD $320 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 No Dental Insurance Welfare Benefit Yes 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 $91,811 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	GUC 0AX6W
Policy instance	5
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 376 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $16,894 Total amount of fees paid to insurance company USD $0 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes 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 $168,936 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	GVTL0AX6W
Policy instance	4
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 253 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $7,049 Total amount of fees paid to insurance company USD $0 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 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 $70,486 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	GUPR0AX6W
Policy instance	3
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 346 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $15,422 Total amount of fees paid to insurance company USD $0 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 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 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 $154,218 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	GLUG0AX6W
Policy instance	2
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 1434 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $12,141 Total amount of fees paid to insurance company USD $0 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 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 Other welfare benefits provided 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 $121,411 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	1
Insurance contract or identification number TM05984020 Number of Individuals Covered 1009 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $36,395 Total amount of fees paid to insurance company USD $282 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 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $370,138 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	GUPR0AX6W
Policy instance	4
Insurance contract or identification number GUPR0AX6W Number of Individuals Covered 241 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $10,446 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 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 $104,461 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,604 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, MIAMI DIV
AETNA HEALTH INC (National Association of Insurance Commissioners NAIC id number: 95088 )
Policy contract number	0835285HNO
Policy instance	7
Insurance contract or identification number 0835285HNO Number of Individuals Covered 1025 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $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 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 $3,920,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Insurance broker organization code? 3 Insurance broker name INSURING SOURCES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC 0AX6W
Policy instance	6
Insurance contract or identification number GUC 0AX6W Number of Individuals Covered 178 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $6,884 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 Yes 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 $68,840 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,383 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, MIAMI DIV
33016-5869 (National Association of Insurance Commissioners NAIC id number: 33016 )
Policy contract number	GVTL0AX6W
Policy instance	5
Insurance contract or identification number GVTL0AX6W Number of Individuals Covered 191 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $3,534 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 $35,339 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,262 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, MIAMI DIV
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AX6W
Policy instance	3
Insurance contract or identification number GLUG0AX6W Number of Individuals Covered 979 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $7,533 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 Other welfare benefits provided 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 $75,329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,961 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, MIAMI DIV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	2
Insurance contract or identification number TM05984020 Number of Individuals Covered 885 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $20,166 Total amount of fees paid to insurance company USD $233 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 No Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $211,295 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,516 Insurance broker organization code? 3 Amount paid for insurance broker fees 15 Additional information about fees paid to insurance broker FEES PAID Insurance broker name BROWN & BROWN OF FLORIDA, INC.
SAFEGUARD HEALTH PLANS, INC. A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	1
Insurance contract or identification number TM05984020 Number of Individuals Covered 619 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $8,360 Total amount of fees paid to insurance company USD $110 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 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 $88,641 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,672 Insurance broker organization code? 3 Amount paid for insurance broker fees 110 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name BROWN & BROWN OF FLORIDA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0835285
Policy instance	8
Insurance contract or identification number 0835285 Number of Individuals Covered 61 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $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 $242,928 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, MIAMI DIV
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	4
Insurance contract or identification number TM05984020 Number of Individuals Covered 445 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $14,613 Total amount of fees paid to insurance company USD $707 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 No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $132,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,613 Amount paid for insurance broker fees 707 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, INC.
SAFEGUARD HEALTH PLANS, INC. A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	3
Insurance contract or identification number TM05984020 Number of Individuals Covered 287 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $4,134 Total amount of fees paid to insurance company USD $207 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 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 $41,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,134 Amount paid for insurance broker fees 207 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	603716
Policy instance	2
Insurance contract or identification number 603716 Number of Individuals Covered 686 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $13,204 Total amount of fees paid to insurance company USD $2,641 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 Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $127,775 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,204 Amount paid for insurance broker fees 2641 Additional information about fees paid to insurance broker ADDITIONAL COMPANSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, INC.
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B22797
Policy instance	1
Insurance contract or identification number B22797 Number of Individuals Covered 704 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $7,961 Total amount of fees paid to insurance company USD $90,726 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 $2,935,924 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,961 Amount paid for insurance broker fees 90726 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, INC.
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	4
Insurance contract or identification number TM05984020 Number of Individuals Covered 186 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $1,910 Total amount of fees paid to insurance company USD $96 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 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 $22,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,910 Amount paid for insurance broker fees 96 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	3
Insurance contract or identification number TM05984020 Number of Individuals Covered 613 Insurance policy start date 2013-06-01 Insurance policy end date 2014-05-31 Total amount of commissions paid to insurance broker USD $16,694 Total amount of fees paid to insurance company USD $1,287 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 No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $164,752 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,694 Amount paid for insurance broker fees 1287 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	6041210000
Policy instance	1
Insurance contract or identification number 6041210000 Number of Individuals Covered 0 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 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 $6,791 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COVENTRY HEALTH CARE OF FLORIDA, INC. (National Association of Insurance Commissioners NAIC id number: 95114 )
Policy contract number	6041210000
Policy instance	2
Insurance contract or identification number 6041210000 Number of Individuals Covered 542 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 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 $2,301,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	3
Insurance contract or identification number TM05984020 Number of Individuals Covered 766 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $18,944 Total amount of fees paid to insurance company USD $4,218 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 No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided 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 $175,010 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,944 Amount paid for insurance broker fees 4218 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	4
Insurance contract or identification number TM05984020 Number of Individuals Covered 183 Insurance policy start date 2012-06-01 Insurance policy end date 2013-05-31 Total amount of commissions paid to insurance broker USD $2,174 Total amount of fees paid to insurance company USD $246 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 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 $21,608 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,174 Amount paid for insurance broker fees 246 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BROWN & BROWN OF FLORIDA, INC.
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	6041210000
Policy instance	1
Insurance contract or identification number 6041210000 Number of Individuals Covered 4 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 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 $15,564 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COVENTRY HEALTH CARE OF FLORIDA, INC. (National Association of Insurance Commissioners NAIC id number: 95114 )
Policy contract number	6041210000
Policy instance	2
Insurance contract or identification number 6041210000 Number of Individuals Covered 479 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 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 $2,440,290 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05984020
Policy instance	3
Insurance contract or identification number TM05984020 Number of Individuals Covered 340 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $8,698 Total amount of fees paid to insurance company USD $3,152 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 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 $87,873 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COVENTRY HEALTH CARE OF FLORIDA, INC. (National Association of Insurance Commissioners NAIC id number: 95114 )
Policy contract number	6041210000
Policy instance	2
Insurance contract or identification number 6041210000 Number of Individuals Covered 476 Insurance policy start date 2011-07-01 Insurance policy end date 2012-06-30 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 $1,938,566 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number	TM05984020
Policy instance	1
Insurance contract or identification number TM05984020 Number of Individuals Covered 175 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $1,440 Total amount of fees paid to insurance company USD $498 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 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 $14,528 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	04374
Policy instance	7
Insurance contract or identification number 04374 Number of Individuals Covered 168 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $8,701 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 Yes 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 $87,012 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	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 305 Insurance policy start date 2010-07-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,754 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 Other welfare benefits provided 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 $17,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 15 Insurance policy start date 2010-07-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $-77 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 Yes 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 $-513 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	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 34 Insurance policy start date 2010-07-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $174 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 $1,159 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	4000300201130
Policy instance	4
Insurance contract or identification number 4000300201130 Number of Individuals Covered 8 Insurance policy start date 2010-07-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $-142 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 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 $-944 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	00423791
Policy instance	5
Insurance contract or identification number 00423791 Number of Individuals Covered 116 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $922 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 Yes 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 $9,217 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COVENTRY HEALTH CARE OF FLORIDA, INC. (National Association of Insurance Commissioners NAIC id number: 95114 )
Policy contract number	6041210000
Policy instance	6
Insurance contract or identification number 6041210000 Number of Individuals Covered 364 Insurance policy start date 2010-07-01 Insurance policy end date 2011-06-30 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 $1,483,756 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	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 34 Insurance policy start date 2010-01-01 Insurance policy end date 2010-06-30 Total amount of commissions paid to insurance broker USD $174 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 $1,159 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	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 305 Insurance policy start date 2010-01-01 Insurance policy end date 2010-06-30 Total amount of commissions paid to insurance broker USD $1,754 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 Other welfare benefits provided 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 $17,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 15 Insurance policy start date 2010-01-01 Insurance policy end date 2010-06-30 Total amount of commissions paid to insurance broker USD $-77 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 Yes 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 $-513 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	40000300201130
Policy instance	4
Insurance contract or identification number 40000300201130 Number of Individuals Covered 8 Insurance policy start date 2010-01-01 Insurance policy end date 2010-06-30 Total amount of commissions paid to insurance broker USD $-142 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 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 $-944 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	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 307 Insurance policy start date 2008-01-01 Insurance policy end date 2008-12-31 Total amount of commissions paid to insurance broker USD $3,235 Total amount of fees paid to insurance company USD $651 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 Other welfare benefits provided 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 $32,345 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,235 Amount paid for insurance broker fees 651 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name HBA INSURANCE GROUP
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 29 Insurance policy start date 2008-01-01 Insurance policy end date 2008-12-31 Total amount of commissions paid to insurance broker USD $3,091 Total amount of fees paid to insurance company USD $476 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 Yes 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 $20,606 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,091 Amount paid for insurance broker fees 476 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name HBA INSURANCE GROUP, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 48 Insurance policy start date 2008-01-01 Insurance policy end date 2008-12-31 Total amount of commissions paid to insurance broker USD $1,755 Total amount of fees paid to insurance company USD $269 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 $11,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,755 Amount paid for insurance broker fees 269 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name HBA INSURANCE GROUP, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300201130
Policy instance	4
Insurance contract or identification number 40000300201130 Number of Individuals Covered 18 Insurance policy start date 2008-01-01 Insurance policy end date 2008-12-31 Total amount of commissions paid to insurance broker USD $3,032 Total amount of fees paid to insurance company USD $498 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 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 $20,211 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,032 Amount paid for insurance broker fees 498 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name HBA INSURANCE GROUP, INC.
AVMED HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 95263 )
Policy contract number	105623/4
Policy instance	5
Insurance contract or identification number 105623/4 Number of Individuals Covered 338 Insurance policy start date 2008-05-01 Insurance policy end date 2009-04-30 Total amount of commissions paid to insurance broker USD $92,919 Total amount of fees paid to insurance company USD $13,077 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 $1,587,687 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $92,919 Amount paid for insurance broker fees 13077 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name WILLIAM BECKHAM
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00423791
Policy instance	6
Insurance contract or identification number 00423791 Number of Individuals Covered 180 Insurance policy start date 2008-03-01 Insurance policy end date 2009-02-28 Total amount of commissions paid to insurance broker USD $9,618 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 Yes Vision Insurance Welfare Benefit Yes 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 $94,842 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,484 Insurance broker organization code? 3 Insurance broker name ALLIANCE FINANCIAL GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 334 Insurance policy start date 2007-01-01 Insurance policy end date 2007-12-31 Total amount of commissions paid to insurance broker USD $2,892 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 Other welfare benefits provided 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 $28,916 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,153 Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 63 Insurance policy start date 2007-01-01 Insurance policy end date 2007-12-31 Total amount of commissions paid to insurance broker USD $3,612 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 Yes 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 $21,161 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,860 Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300201130
Policy instance	4
Insurance contract or identification number 40000300201130 Number of Individuals Covered 33 Insurance policy start date 2007-01-01 Insurance policy end date 2007-12-31 Total amount of commissions paid to insurance broker USD $3,051 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 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 $22,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,016 Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 89 Insurance policy start date 2007-01-01 Insurance policy end date 2007-12-31 Total amount of commissions paid to insurance broker USD $2,039 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 $11,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,063 Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
AVMED HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 95263 )
Policy contract number	105623/4
Policy instance	5
Insurance contract or identification number 105623/4 Number of Individuals Covered 337 Insurance policy start date 2007-05-01 Insurance policy end date 2008-04-30 Total amount of commissions paid to insurance broker USD $77,640 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 $1,294,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $77,640 Insurance broker organization code? 3 Insurance broker name GROUP BENEFIT CONCEPTS, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00423791
Policy instance	6
Insurance contract or identification number 00423791 Number of Individuals Covered 175 Insurance policy start date 2007-03-01 Insurance policy end date 2008-02-29 Total amount of commissions paid to insurance broker USD $6,757 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 Yes Vision Insurance Welfare Benefit Yes 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 $65,097 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,510 Insurance broker organization code? 3 Insurance broker name ALLIANCE FINANCIAL GROUP
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 77 Insurance policy start date 2006-01-01 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $3,507 Total amount of fees paid to insurance company USD $2,387 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 Yes 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 $23,382 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,507 Amount paid for insurance broker fees 2387 Additional information about fees paid to insurance broker OVERRIDE AND BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 265 Insurance policy start date 2006-01-01 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $2,264 Total amount of fees paid to insurance company USD $854 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 Other welfare benefits provided 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 $22,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,264 Amount paid for insurance broker fees 854 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300201130
Policy instance	4
Insurance contract or identification number 40000300201130 Number of Individuals Covered 45 Insurance policy start date 2006-01-01 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $4,466 Total amount of fees paid to insurance company USD $1,137 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 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 $29,773 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,466 Amount paid for insurance broker fees 1137 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
AVMED HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 95263 )
Policy contract number	105623/4
Policy instance	5
Insurance contract or identification number 105623/4 Number of Individuals Covered 293 Insurance policy start date 2006-05-01 Insurance policy end date 2007-04-30 Total amount of commissions paid to insurance broker USD $80,158 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 $1,154,358 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80,158 Insurance broker organization code? 3 Insurance broker name HBA INSURANCE GROUP, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 109 Insurance policy start date 2006-01-01 Insurance policy end date 2006-12-31 Total amount of commissions paid to insurance broker USD $2,652 Total amount of fees paid to insurance company USD $617 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 $13,262 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,652 Amount paid for insurance broker fees 617 Additional information about fees paid to insurance broker OVERRIDE AND BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000300201130
Policy instance	4
Insurance contract or identification number 40000300201130 Number of Individuals Covered 58 Insurance policy start date 2005-01-01 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $5,249 Total amount of fees paid to insurance company USD $844 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 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 $34,992 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,249 Amount paid for insurance broker fees 844 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	40000100003471
Policy instance	3
Insurance contract or identification number 40000100003471 Number of Individuals Covered 130 Insurance policy start date 2005-01-01 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $3,657 Total amount of fees paid to insurance company USD $544 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 $18,983 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,657 Amount paid for insurance broker fees 544 Additional information about fees paid to insurance broker OVERRIDE AND BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	40000200001030
Policy instance	2
Insurance contract or identification number 40000200001030 Number of Individuals Covered 97 Insurance policy start date 2005-01-01 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $5,621 Total amount of fees paid to insurance company USD $2,844 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 Yes 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 $37,472 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,621 Amount paid for insurance broker fees 2844 Additional information about fees paid to insurance broker OVERRIDE AND BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )
Policy contract number	10046683
Policy instance	1
Insurance contract or identification number 10046683 Number of Individuals Covered 312 Insurance policy start date 2005-01-01 Insurance policy end date 2005-12-31 Total amount of commissions paid to insurance broker USD $2,626 Total amount of fees paid to insurance company USD $640 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 Other welfare benefits provided 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 $26,263 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,626 Amount paid for insurance broker fees 640 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name THE HERGET COMPANY