PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 401k Plan overview

Plan Name	PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN
Plan identification number	501

PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION 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

401k Sponsoring company profile

PHIL SMITH MANAGEMENT, INC. DBA PHIL SMITH AUTOMOTIVE GROUP has sponsored the creation of one or more 401k plans.

Company Name:	PHIL SMITH MANAGEMENT, INC. DBA PHIL SMITH AUTOMOTIVE GROUP
Employer identification number (EIN):	650838041
NAIC Classification:	441110
NAIC Description:	New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-03-01	MICHAEL DAYHOFF	2020-11-30	MICHAEL DAYHOFF	2020-11-30
501	2018-03-01			MIKE DAYHOFF	2019-11-22
501	2018-03-01	MIKE DAYHOFF	2019-11-22	MIKE DAYHOFF	2019-11-22
501	2017-03-01
501	2016-03-01
501	2015-03-01
501	2015-03-01
501	2014-03-01
501	2013-03-01
501	2012-03-01	MIKE DAYHOFF
501	2012-01-01	MICHAEL R. DAYHOFF, CFO
501	2011-01-01	MICHAEL R. DAYHOFF, CFO
501	2009-01-01	MICHAEL R. DAYHOFF, CFO

Plan Statistics for PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN

401k plan membership statisitcs for PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN

Measure	Date	Value
2019: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-03-01	297
Total of all active and inactive participants	2019-03-01	0
Total participants	2019-03-01	0
2018: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	460
Total of all active and inactive participants	2018-03-01	0
Total participants	2018-03-01	0
2017: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	460
Total of all active and inactive participants	2017-03-01	0
Total participants	2017-03-01	0
2016: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	460
Total of all active and inactive participants	2016-03-01	0
Total participants	2016-03-01	0
2015: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	460
Total of all active and inactive participants	2015-03-01	0
Total participants	2015-03-01	0
2014: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	460
Total of all active and inactive participants	2014-03-01	0
Total participants	2014-03-01	0
2013: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	460
Total of all active and inactive participants	2013-03-01	0
Total participants	2013-03-01	0
2012: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	460
Total of all active and inactive participants	2012-03-01	0
Total participants	2012-03-01	0
Total participants, beginning-of-year	2012-01-01	466
Total of all active and inactive participants	2012-01-01	0
Total participants	2012-01-01	0
2011: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	466
Total of all active and inactive participants	2011-01-01	0
Total participants	2011-01-01	0
2009: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	410
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	385
Number of retired or separated participants receiving benefits	2009-01-01	15
Total of all active and inactive participants	2009-01-01	400

Form 5500 Responses for PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN

2019: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2018: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2017: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2016: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2015: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: PHIL SMITH AUTOMOTIVE GROUP PRE-TAX CONVERSION PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	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	G000AC82
Policy instance	6
Insurance contract or identification number G000AC82 Number of Individuals Covered 12 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $2,086 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,086 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	18
Insurance contract or identification number 857515G Number of Individuals Covered 20 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $2,368 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,814 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,368 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	19
Insurance contract or identification number 851899G Number of Individuals Covered 37 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $9,507 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $47,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,507 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	938991
Policy instance	20
Insurance contract or identification number 938991 Number of Individuals Covered 49 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $2,032 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,308 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,032 Additional information about fees paid to insurance broker BENEFITS CONSUTATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAKC
Policy instance	4
Insurance contract or identification number G000AAKC Number of Individuals Covered 54 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-28 Total amount of commissions paid to insurance broker USD $5,616 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,077 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,808 Additional information about fees paid to insurance broker BROKERS SERVICES Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )
Policy contract number	29303
Policy instance	3
Insurance contract or identification number 29303 Number of Individuals Covered 38 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $13,344 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,344 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	2
Insurance contract or identification number 29303 Number of Individuals Covered 22 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $11,152 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,152 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AINX
Policy instance	1
Insurance contract or identification number G000AINX Number of Individuals Covered 60 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $3,394 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,971 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,394 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780562
Policy instance	13
Insurance contract or identification number 780562 Number of Individuals Covered 96 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $5,770 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $57,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,454 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	8553353G
Policy instance	17
Insurance contract or identification number 8553353G Number of Individuals Covered 24 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $2,573 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,869 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,573 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	796822
Policy instance	15
Insurance contract or identification number 796822 Number of Individuals Covered 24 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $1,668 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,996 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,314 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	16
Insurance contract or identification number 854844G Number of Individuals Covered 20 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $1,684 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,421 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,684 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAQ5
Policy instance	7
Insurance contract or identification number G000AAQ5 Number of Individuals Covered 27 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $2,968 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,838 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,968 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5722841
Policy instance	8
Insurance contract or identification number 5722841 Number of Individuals Covered 73 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $1,299 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,738 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,299 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00533699
Policy instance	9
Insurance contract or identification number 00533699 Number of Individuals Covered 60 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $1,200 Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,534 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,177 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780670
Policy instance	10
Insurance contract or identification number 780670 Number of Individuals Covered 35 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $3,211 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,538 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	780670
Policy instance	11
Insurance contract or identification number 780670 Number of Individuals Covered 16 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $326 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,868 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $297 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780642
Policy instance	12
Insurance contract or identification number 780642 Number of Individuals Covered 57 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $44,984 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	G000ABLA
Policy instance	5
Insurance contract or identification number G000ABLA Number of Individuals Covered 24 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $3,896 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $19,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,896 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	780562
Policy instance	14
Insurance contract or identification number 780562 Number of Individuals Covered 57 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $1,804 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $89,121 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,654 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTLOAINX
Policy instance	1
Insurance contract or identification number GVTLOAINX Number of Individuals Covered 19 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,106 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,532 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,106 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515
Policy instance	29
Insurance contract or identification number 857515 Number of Individuals Covered 8 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,829 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $15,116 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,829 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780642
Policy instance	2
Insurance contract or identification number 780642 Number of Individuals Covered 41 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $35,688 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	G00AC82
Policy instance	20
Insurance contract or identification number G00AC82 Number of Individuals Covered 21 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,856 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,281 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,856 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
GUARDIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	533699
Policy instance	4
Insurance contract or identification number 533699 Number of Individuals Covered 52 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,695 Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,198 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,147 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	208000
Policy instance	3
Insurance contract or identification number 208000 Number of Individuals Covered 110 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $22,736 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $568,390 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,736 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5722841
Policy instance	5
Insurance contract or identification number 5722841 Number of Individuals Covered 80 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,174 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,864 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,174 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AC82
Policy instance	7
Insurance contract or identification number G000AC82 Number of Individuals Covered 21 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,856 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,281 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,856 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTLA0AAQ5
Policy instance	19
Insurance contract or identification number GVTLA0AAQ5 Number of Individuals Covered 43 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $3,185 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $15,924 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,185 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AKCC
Policy instance	18
Insurance contract or identification number G000AKCC Number of Individuals Covered 60 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $5,388 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $26,938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,694 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780562
Policy instance	17
Insurance contract or identification number 780562 Number of Individuals Covered 101 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $4,605 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $86,839 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,605 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	46225
Policy instance	8
Insurance contract or identification number 46225 Number of Individuals Covered 51 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $38,272 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,272 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
CAPITAL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95112 )
Policy contract number	00366
Policy instance	11
Insurance contract or identification number 00366 Number of Individuals Covered 92 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $18,884 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $625,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,884 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )
Policy contract number	19146
Policy instance	15
Insurance contract or identification number 19146 Number of Individuals Covered 112 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-21 Total amount of commissions paid to insurance broker USD $19,782 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $116,483 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,474 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	119740
Policy instance	14
Insurance contract or identification number 119740 Number of Individuals Covered 15 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $269 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,695 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $269 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780670
Policy instance	12
Insurance contract or identification number 780670 Number of Individuals Covered 36 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,051 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,051 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL146022
Policy instance	13
Insurance contract or identification number GL146022 Number of Individuals Covered 68 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $372 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,723 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $372 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	796822
Policy instance	9
Insurance contract or identification number 796822 Number of Individuals Covered 23 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,035 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,202 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,035 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	46225
Policy instance	21
Insurance contract or identification number 46225 Number of Individuals Covered 51 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $38,272 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,272 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0ABLA
Policy instance	10
Insurance contract or identification number GVTL0ABLA Number of Individuals Covered 30 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $4,399 Commission paid to Insurance Broker USD $4,399 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	697614
Policy instance	16
Insurance contract or identification number 697614 Number of Individuals Covered 139 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $40,527 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,097,596 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40,527 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	855353G
Policy instance	28
Insurance contract or identification number 855353G Number of Individuals Covered 13 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,485 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,426 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,485 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	27
Insurance contract or identification number 854844G Number of Individuals Covered 7 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,390 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,390 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	8W6088
Policy instance	6
Insurance contract or identification number 8W6088 Number of Individuals Covered 43 Insurance policy start date 2018-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $11,714 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $349,406 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,714 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
CAPITAL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95112 )
Policy contract number	00366
Policy instance	24
Insurance contract or identification number 00366 Number of Individuals Covered 92 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $18,884 Welfare Benefit Premiums Paid to Carrier USD $625,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,884 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	26
Insurance contract or identification number 851899G Number of Individuals Covered 38 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $10,087 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $50,437 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,087 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780670
Policy instance	25
Insurance contract or identification number 780670 Number of Individuals Covered 36 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $2,052 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,052 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000ABLA
Policy instance	23
Insurance contract or identification number G000ABLA Number of Individuals Covered 30 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $4,399 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,399 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	796822
Policy instance	22
Insurance contract or identification number 796822 Number of Individuals Covered 23 Insurance policy start date 2018-03-01 Insurance policy end date 2019-02-28 Total amount of commissions paid to insurance broker USD $1,035 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,202 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,035 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3721, CP3721,
Policy instance	30
Insurance contract or identification number CD3721, CP3721, Number of Individuals Covered 40 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $1,448 Welfare Benefit Premiums Paid to Carrier USD $20,635 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $191 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780670
Policy instance	32
Insurance contract or identification number 780670 Number of Individuals Covered 268 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $269 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,995 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $269 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
THE HARTFORD (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	20
Insurance contract or identification number 854844G Number of Individuals Covered 34 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,522 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,831 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,522 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	780562
Policy instance	31
Insurance contract or identification number 780562 Number of Individuals Covered 80 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $784 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,760 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $784 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	CD0393, CP0393,
Policy instance	29
Insurance contract or identification number CD0393, CP0393, Number of Individuals Covered 15 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $911 Welfare Benefit Premiums Paid to Carrier USD $14,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $130 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	08W6088
Policy instance	4
Insurance contract or identification number 08W6088 Number of Individuals Covered 49 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $13,376 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $365,301 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,376 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVIS BLAIR ADAMS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AC82
Policy instance	16
Insurance contract or identification number G000AC82 Number of Individuals Covered 16 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,174 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,870 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 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	655323
Policy instance	7
Insurance contract or identification number 655323 Number of Individuals Covered 80 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $24,235 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $329,372 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,235 Additional information about fees paid to insurance broker BROKER SEWRVICES Insurance broker organization code? 3 Insurance broker name DAVID BLAIR ADAMS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAKC
Policy instance	15
Insurance contract or identification number G000AAKC Number of Individuals Covered 59 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $4,924 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $24,619 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,462 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name STEVEN CHOCRANE
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3729, CP3729,
Policy instance	28
Insurance contract or identification number CD3729, CP3729, Number of Individuals Covered 49 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $1,935 Welfare Benefit Premiums Paid to Carrier USD $28,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $276 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAQ5
Policy instance	13
Insurance contract or identification number G000AAQ5 Number of Individuals Covered 22 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,794 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,970 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,794 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	12
Insurance contract or identification number 857515G Number of Individuals Covered 6 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,899 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,527 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,899 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	11
Insurance contract or identification number 851899G Number of Individuals Covered 40 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $10,715 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $53,577 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,715 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	92729303
Policy instance	10
Insurance contract or identification number 92729303 Number of Individuals Covered 60 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $1,824 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,448 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,824 Additional information about fees paid to insurance broker 3 Insurance broker name EBS ADVISORS
AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )
Policy contract number	19146
Policy instance	9
Insurance contract or identification number 19146 Number of Individuals Covered 119 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $24,218 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $111,309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,455 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )
Policy contract number	19146
Policy instance	8
Insurance contract or identification number 19146 Number of Individuals Covered 119 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $24,220 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $134,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,456 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
CAPITAL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95112 )
Policy contract number	00366
Policy instance	6
Insurance contract or identification number 00366 Number of Individuals Covered 111 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $17,417 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $599,717 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,417 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	KE818,KE13,9K30
Policy instance	5
Insurance contract or identification number KE818,KE13,9K30 Number of Individuals Covered 50 Insurance policy start date 2016-12-01 Insurance policy end date 2017-11-30 Total amount of commissions paid to insurance broker USD $1,319 Total amount of fees paid to insurance company USD $36 Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,898 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,227 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Amount paid for insurance broker fees 36 Insurance broker name ADAMS BENEFIT CORP
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05722841
Policy instance	3
Insurance contract or identification number TM05722841 Number of Individuals Covered 53 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $1,187 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,248 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,187 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	20800
Policy instance	2
Insurance contract or identification number 20800 Number of Individuals Covered 110 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $23,152 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $578,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,991 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name GEORGE LITTLE AND ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000ABLA
Policy instance	14
Insurance contract or identification number G000ABLA Number of Individuals Covered 28 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $4,280 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,399 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,280 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	439653
Policy instance	1
Insurance contract or identification number 439653 Number of Individuals Covered 157 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $35,907 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $589,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,907 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORP
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3727, CP3727,
Policy instance	27
Insurance contract or identification number CD3727, CP3727, Number of Individuals Covered 11 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $491 Welfare Benefit Premiums Paid to Carrier USD $6,530 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $70 Additional information about fees paid to insurance broker BROKER SERVICESD Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3733, CD3734
Policy instance	26
Insurance contract or identification number CD3733, CD3734 Number of Individuals Covered 48 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $518 Welfare Benefit Premiums Paid to Carrier USD $37,890 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $183 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3723, CP3723,
Policy instance	25
Insurance contract or identification number CD3723, CP3723, Number of Individuals Covered 70 Insurance policy start date 2017-03-01 Insurance policy end date 2017-02-28 Total amount of commissions paid to insurance broker USD $2,659 Welfare Benefit Premiums Paid to Carrier USD $38,267 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $379 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )
Policy contract number	19146
Policy instance	24
Insurance contract or identification number 19146 Number of Individuals Covered 119 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $24,220 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $111,309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,456 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	23
Insurance contract or identification number 851899G Number of Individuals Covered 88 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $10,715 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $53,577 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,715 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	LTD119740
Policy instance	22
Insurance contract or identification number LTD119740 Number of Individuals Covered 12 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $215 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,155 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $215 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL146022
Policy instance	21
Insurance contract or identification number GL146022 Number of Individuals Covered 67 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $286 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,868 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $286 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	855353G
Policy instance	19
Insurance contract or identification number 855353G Number of Individuals Covered 25 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $22,224 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,120 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,224 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	18
Insurance contract or identification number 857515G Number of Individuals Covered 20 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $2,899 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,527 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,899 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	02X3757
Policy instance	17
Insurance contract or identification number 02X3757 Number of Individuals Covered 94 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $21,201 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $403,830 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,201 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3727 28 CP372
Policy instance	9
Insurance contract or identification number CD3727 28 CP372 Number of Individuals Covered 9 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $343 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	855353G
Policy instance	2
Insurance contract or identification number 855353G Number of Individuals Covered 11 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $2,838 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,191 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,838 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3729 30 CP372
Policy instance	10
Insurance contract or identification number CD3729 30 CP372 Number of Individuals Covered 37 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $2,224 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $25,581 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $252 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3723 24 CP372
Policy instance	8
Insurance contract or identification number CD3723 24 CP372 Number of Individuals Covered 62 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $2,857 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,403 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $370 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	92929303
Policy instance	7
Insurance contract or identification number 92929303 Number of Individuals Covered 58 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $21,330 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $362,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,330 Additional information about fees paid to insurance broker CONSULTING SERVICES Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AC82
Policy instance	6
Insurance contract or identification number G000AC82 Number of Individuals Covered 24 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,246 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,230 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,246 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000AAQ5
Policy instance	5
Insurance contract or identification number G000AAQ5 Number of Individuals Covered 28 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,359 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,796 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,359 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	4
Insurance contract or identification number 857515G Number of Individuals Covered 6 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $1,570 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,850 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,570 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	3
Insurance contract or identification number 854844G Number of Individuals Covered 11 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $2,451 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,451 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	1
Insurance contract or identification number 851899G Number of Individuals Covered 22 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $6,174 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $30,870 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,174 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3733 34
Policy instance	11
Insurance contract or identification number CD3733 34 Number of Individuals Covered 50 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $377 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $34,633 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $332 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5263
Policy instance	12
Insurance contract or identification number VS5263 Number of Individuals Covered 10 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $88 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $979 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $88 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5261
Policy instance	13
Insurance contract or identification number VS5261 Number of Individuals Covered 49 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $483 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,396 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $483 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE GROUP
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05722841
Policy instance	21
Insurance contract or identification number TM05722841 Number of Individuals Covered 47 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $993 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,204 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $687 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	655323
Policy instance	20
Insurance contract or identification number 655323 Number of Individuals Covered 47 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $12,699 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $253,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,699 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID BLAIR ADAMS
CAPITAL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95112 )
Policy contract number	00366
Policy instance	19
Insurance contract or identification number 00366 Number of Individuals Covered 84 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $13,247 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $479,348 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,247 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID ADAMS
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number	50019725
Policy instance	18
Insurance contract or identification number 50019725 Number of Individuals Covered 27 Insurance policy start date 2014-12-01 Insurance policy end date 2015-11-30 Total amount of commissions paid to insurance broker USD $682 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,022 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $116 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name MOSAIC GROUP
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3719 CP3719 2
Policy instance	17
Insurance contract or identification number CD3719 CP3719 2 Number of Individuals Covered 10 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $234 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,693 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3721 22 CP372
Policy instance	16
Insurance contract or identification number CD3721 22 CP372 Number of Individuals Covered 46 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $1,661 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,959 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $193 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS6327
Policy instance	15
Insurance contract or identification number VS6327 Number of Individuals Covered 11 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $84 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $939 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $84 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5268
Policy instance	14
Insurance contract or identification number VS5268 Number of Individuals Covered 5 Insurance policy start date 2015-03-01 Insurance policy end date 2016-02-29 Total amount of commissions paid to insurance broker USD $25 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $283 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	655323
Policy instance	7
Insurance contract or identification number 655323 Number of Individuals Covered 49 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $12,250 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $233,343 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,250 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID BLAIR ADAMS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	855353G
Policy instance	6
Insurance contract or identification number 855353G Number of Individuals Covered 12 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,526 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,630 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,526 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GOOOABLA
Policy instance	5
Insurance contract or identification number GOOOABLA Number of Individuals Covered 20 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $3,035 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $15,174 Commission paid to Insurance Broker USD $3,035 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	4
Insurance contract or identification number 857515G Number of Individuals Covered 6 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $1,465 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $7,325 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,465 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GOOOAAQ5
Policy instance	3
Insurance contract or identification number GOOOAAQ5 Number of Individuals Covered 14 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $1,377 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $6,885 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,377 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	208000
Policy instance	2
Insurance contract or identification number 208000 Number of Individuals Covered 92 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $17,172 Welfare Benefit Premiums Paid to Carrier USD $429,303 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,172 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name THE MGN COMPANY
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )
Policy contract number	29303
Policy instance	9
Insurance contract or identification number 29303 Number of Individuals Covered 36 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $7,150 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,150 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	8
Insurance contract or identification number 29303 Number of Individuals Covered 17 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $6,522 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,522 Additional information about fees paid to insurance broker BENEFIT CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	079503
Policy instance	10
Insurance contract or identification number 079503 Number of Individuals Covered 40 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $13,152 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,152 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DAVID B ADAMS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GOOOAAKC
Policy instance	11
Insurance contract or identification number GOOOAAKC Number of Individuals Covered 45 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,726 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $27,259 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,726 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name KENNETH ROBERTS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	12
Insurance contract or identification number 851899G Number of Individuals Covered 19 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $6,991 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $34,956 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,991 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GOOOAC82
Policy instance	13
Insurance contract or identification number GOOOAC82 Number of Individuals Covered 16 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $1,702 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $8,512 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,702 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	14
Insurance contract or identification number 854844G Number of Individuals Covered 13 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,703 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,515 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,703 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	15
Insurance contract or identification number B15448 Number of Individuals Covered 145 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $1,196 Total amount of fees paid to insurance company USD $31,145 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $746,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,196 Amount paid for insurance broker fees 31145 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORP
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	438652 439653
Policy instance	16
Insurance contract or identification number 438652 439653 Number of Individuals Covered 38 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $11,193 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $273,130 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,193 Additional information about fees paid to insurance broker BROKER SERVICED Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GOOOAINX
Policy instance	1
Insurance contract or identification number GOOOAINX Number of Individuals Covered 19 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,197 Other welfare benefits provided VOL LIFE Welfare Benefit Premiums Paid to Carrier USD $10,983 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,197 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRO HEALTH USA
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	VS5269
Policy instance	11
Insurance contract or identification number VS5269 Number of Individuals Covered 50 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $112 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,138 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $112 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name JB INSURANCE SERVICES
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	1
Insurance contract or identification number B15448 Number of Individuals Covered 136 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of fees paid to insurance company USD $33,193 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $672,714 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 33193 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORPORATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	6231,AAKC,AC82,
Policy instance	14
Insurance contract or identification number 6231,AAKC,AC82, Number of Individuals Covered 165 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $12,508 Commission paid to Insurance Broker USD $6,414 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name STEVEN COCHRANE
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G,854844G
Policy instance	13
Insurance contract or identification number 851899G,854844G Number of Individuals Covered 226 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $16,019 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $81,302 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,543 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DEANNA AUTREY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	438652
Policy instance	2
Insurance contract or identification number 438652 Number of Individuals Covered 141 Insurance policy start date 2012-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $14,443 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $350,578 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,443 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORPORATION
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	3721,3729,CD530
Policy instance	12
Insurance contract or identification number 3721,3729,CD530 Number of Individuals Covered 128 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $4,113 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $61,672 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $531 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5268
Policy instance	10
Insurance contract or identification number VS5268 Number of Individuals Covered 5 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $52 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $582 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name PRIMEGROUP INSURANCE SERVICES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	146022
Policy instance	9
Insurance contract or identification number 146022 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $2,430 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,160 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,430 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY INC
SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )
Policy contract number	002646
Policy instance	8
Insurance contract or identification number 002646 Number of Individuals Covered 3 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $366 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,440 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $366 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name EBENCONCEPTS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	119740
Policy instance	7
Insurance contract or identification number 119740 Number of Individuals Covered 11 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $200 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,995 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $200 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY INC
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	208000
Policy instance	6
Insurance contract or identification number 208000 Number of Individuals Covered 107 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $17,002 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $425,055 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,002 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name THE MGN GROUP
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05599796
Policy instance	5
Insurance contract or identification number TM05599796 Number of Individuals Covered 116 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $1,319 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,640 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,319 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	3
Insurance contract or identification number 29303 Number of Individuals Covered 14 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $4,713 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $117,830 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,713 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )
Policy contract number	29303
Policy instance	4
Insurance contract or identification number 29303 Number of Individuals Covered 39 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $8,126 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $203,141 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,126 Additional information about fees paid to insurance broker BENEFITS CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )
Policy contract number	SD26460001
Policy instance	11
Insurance contract or identification number SD26460001 Number of Individuals Covered 5 Insurance policy start date 2012-03-01 Insurance policy end date 2012-02-28 Total amount of commissions paid to insurance broker USD $533 Welfare Benefit Premiums Paid to Carrier USD $3,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $462 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name MEL SCHLESINGER
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05599796
Policy instance	12
Insurance contract or identification number TM05599796 Number of Individuals Covered 131 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $1,057 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $25,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,057 Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL146022
Policy instance	14
Insurance contract or identification number GL146022 Number of Individuals Covered 70 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $245 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,464 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $245 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY, INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	119740
Policy instance	13
Insurance contract or identification number 119740 Number of Individuals Covered 13 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $280 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,791 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $280 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name CUNDY, INC
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	VS8183
Policy instance	10
Insurance contract or identification number VS8183 Number of Individuals Covered 17 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,298 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	9
Insurance contract or identification number B15448 Number of Individuals Covered 161 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $31,868 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $730,790 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,868 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORP
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	208000
Policy instance	8
Insurance contract or identification number 208000 Number of Individuals Covered 118 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $17,766 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $444,153 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,766 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name THE MGN COMPANY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G,854844G
Policy instance	7
Insurance contract or identification number 857515G,854844G Number of Individuals Covered 231 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $18,129 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $91,862 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,140 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name DEANNA AUTREY
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )
Policy contract number	29303
Policy instance	6
Insurance contract or identification number 29303 Number of Individuals Covered 49 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $8,058 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,058 Additional information about fees paid to insurance broker BENEFIT CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	5
Insurance contract or identification number 29303 Number of Individuals Covered 12 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $3,834 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,834 Additional information about fees paid to insurance broker BENEFIT CONSULTATION Insurance broker organization code? 3 Insurance broker name EBS ADVISORS, INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	438652 / 439653
Policy instance	4
Insurance contract or identification number 438652 / 439653 Number of Individuals Covered 157 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $10,736 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $284,222 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,736 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name ADAMS BENEFIT CORP
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1036221000
Policy instance	3
Insurance contract or identification number 1036221000 Number of Individuals Covered 68 Insurance policy start date 2011-07-01 Insurance policy end date 2012-06-30 Total amount of commissions paid to insurance broker USD $18,896 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $394,862 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,896 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name FIDELITY INSURANCE AGENCY
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3735, CP3736
Policy instance	2
Insurance contract or identification number CD3735, CP3736 Number of Individuals Covered 38 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $1,052 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,392 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $122 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name FIRST FINANCIAL ADVISORS OF FLORIDA
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000623I
Policy instance	1
Insurance contract or identification number G000623I Number of Individuals Covered 46 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $19,091 Other welfare benefits provided VOLUNTARY LIFE Welfare Benefit Premiums Paid to Carrier USD $95,455 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,877 Additional information about fees paid to insurance broker BROKER SERVICES Insurance broker organization code? 3 Insurance broker name STEVEN COCHRANE
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5261,5262,526
Policy instance	2
Insurance contract or identification number VS5261,5262,526 Number of Individuals Covered 63 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	6231,AAKC
Policy instance	5
Insurance contract or identification number 6231,AAKC Number of Individuals Covered 105 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Other welfare benefits provided VOLUNTARY LIFE Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD 393,394,3719
Policy instance	1
Insurance contract or identification number CD 393,394,3719 Number of Individuals Covered 86 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G,854844G
Policy instance	3
Insurance contract or identification number 851899G,854844G Number of Individuals Covered 210 Insurance policy start date 2011-01-01 Insurance policy end date 2012-12-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	ABLA,AG7H,AAQ5,
Policy instance	4
Insurance contract or identification number ABLA,AG7H,AAQ5, Number of Individuals Covered 80 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Other welfare benefits provided VOLUNTARY LIFE Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	20800
Policy instance	14
Insurance contract or identification number 20800 Number of Individuals Covered 116 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	439653
Policy instance	13
Insurance contract or identification number 439653 Number of Individuals Covered 38 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05599796
Policy instance	11
Insurance contract or identification number TM05599796 Number of Individuals Covered 122 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	146022
Policy instance	10
Insurance contract or identification number 146022 Number of Individuals Covered 79 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Life Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	119740
Policy instance	9
Insurance contract or identification number 119740 Number of Individuals Covered 14 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Long Term Disability Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	8
Insurance contract or identification number 29303 Number of Individuals Covered 69 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	1036221000
Policy instance	7
Insurance contract or identification number 1036221000 Number of Individuals Covered 96 Insurance policy start date 2010-07-01 Insurance policy end date 2011-06-30 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	6
Insurance contract or identification number B15448 Number of Individuals Covered 188 Insurance policy start date 2010-08-01 Insurance policy end date 2011-02-28 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number	1036221000
Policy instance	7
Insurance contract or identification number 1036221000 Number of Individuals Covered 96 Insurance policy start date 2010-07-01 Insurance policy end date 2011-06-30 Total amount of commissions paid to insurance broker USD $12,598 Total amount of fees paid to insurance company USD $18 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $249,670 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	6
Insurance contract or identification number B15448 Number of Individuals Covered 188 Insurance policy start date 2010-08-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $26,633 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $448,507 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G,854844G
Policy instance	3
Insurance contract or identification number 851899G,854844G Number of Individuals Covered 210 Insurance policy start date 2011-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $16,870 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $81,840 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	6231,AAKC
Policy instance	5
Insurance contract or identification number 6231,AAKC Number of Individuals Covered 105 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $10,573 Other welfare benefits provided VOLUNTARY LIFE Welfare Benefit Premiums Paid to Carrier USD $52,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5261,5262,526
Policy instance	2
Insurance contract or identification number VS5261,5262,526 Number of Individuals Covered 63 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,234 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $19,989 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD 393,394,3719
Policy instance	1
Insurance contract or identification number CD 393,394,3719 Number of Individuals Covered 86 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $4,630 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $56,505 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	ABLA,AG7H,AAQ5,
Policy instance	4
Insurance contract or identification number ABLA,AG7H,AAQ5, Number of Individuals Covered 80 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $7,531 Other welfare benefits provided VOLUNTARY LIFE Welfare Benefit Premiums Paid to Carrier USD $37,654 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	8
Insurance contract or identification number 29303 Number of Individuals Covered 69 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $12,421 Health Insurance Welfare Benefit Yes
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	119740
Policy instance	9
Insurance contract or identification number 119740 Number of Individuals Covered 14 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $230 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	146022
Policy instance	10
Insurance contract or identification number 146022 Number of Individuals Covered 79 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $289 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,893 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	TM05599796
Policy instance	11
Insurance contract or identification number TM05599796 Number of Individuals Covered 122 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $1,451 Total amount of fees paid to insurance company USD $26 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $23,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	439653
Policy instance	13
Insurance contract or identification number 439653 Number of Individuals Covered 38 Insurance policy start date 2010-03-01 Insurance policy end date 2011-02-28 Total amount of commissions paid to insurance broker USD $14,213 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $231,030 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	20800
Policy instance	14
Insurance contract or identification number 20800 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 $15,570 Welfare Benefit Premiums Paid to Carrier USD $389,255 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	G000AG7H
Policy instance	36
Insurance contract or identification number G000AG7H Number of Individuals Covered 12 Insurance policy start date 2010-06-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $385 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,927 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	GVTL0AAQ5
Policy instance	27
Insurance contract or identification number GVTL0AAQ5 Number of Individuals Covered 13 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $897 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NEIGHBORHOOD HEALTH PARTNERSHIP (National Association of Insurance Commissioners NAIC id number: 95123 )
Policy contract number	B15448
Policy instance	18
Insurance contract or identification number B15448 Number of Individuals Covered 146 Insurance policy start date 2009-03-01 Insurance policy end date 2010-02-28 Total amount of commissions paid to insurance broker USD $32,862 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $547,698 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	GVTL0623I
Policy instance	14
Insurance contract or identification number GVTL0623I Number of Individuals Covered 24 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,890 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,448 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3729 & CD3730
Policy instance	10
Insurance contract or identification number CD3729 & CD3730 Number of Individuals Covered 28 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,357 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $18,195 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	46225
Policy instance	1
Insurance contract or identification number 46225 Number of Individuals Covered 25 Insurance policy start date 2009-03-01 Insurance policy end date 2010-02-28 Total amount of commissions paid to insurance broker USD $10,497 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIRSTCAROLINACARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	208000
Policy instance	2
Insurance contract or identification number 208000 Number of Individuals Covered 119 Insurance policy start date 2009-03-01 Insurance policy end date 2010-02-28 Total amount of commissions paid to insurance broker USD $12,431 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $310,775 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5261
Policy instance	3
Insurance contract or identification number VS5261 Number of Individuals Covered 17 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $204 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,001 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	854844G
Policy instance	21
Insurance contract or identification number 854844G Number of Individuals Covered 62 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $3,359 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	855353G
Policy instance	22
Insurance contract or identification number 855353G Number of Individuals Covered 35 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,226 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,132 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	439653
Policy instance	23
Insurance contract or identification number 439653 Number of Individuals Covered 31 Insurance policy start date 2009-03-01 Insurance policy end date 2010-02-28 Total amount of commissions paid to insurance broker USD $9,927 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $154,735 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5263
Policy instance	24
Insurance contract or identification number VS5263 Number of Individuals Covered 3 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $43 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $403 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3719, CP3719
Policy instance	25
Insurance contract or identification number CD3719, CP3719 Number of Individuals Covered 7 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $531 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $6,583 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3733
Policy instance	26
Insurance contract or identification number CD3733 Number of Individuals Covered 29 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,497 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $21,761 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	GVTL0ABLA
Policy instance	28
Insurance contract or identification number GVTL0ABLA Number of Individuals Covered 20 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,441 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,203 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	GVTL0AAKC
Policy instance	29
Insurance contract or identification number GVTL0AAKC Number of Individuals Covered 48 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $5,588 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $27,936 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	29303
Policy instance	30
Insurance contract or identification number 29303 Number of Individuals Covered 71 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Total amount of commissions paid to insurance broker USD $10,908 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 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	TM05599796
Policy instance	31
Insurance contract or identification number TM05599796 Number of Individuals Covered 120 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,445 Total amount of fees paid to insurance company USD $26 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,418 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7900061
Policy instance	32
Insurance contract or identification number E7900061 Number of Individuals Covered 27 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,665 Total amount of fees paid to insurance company USD $287 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,742 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CAPITAL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95112 )
Policy contract number	00366
Policy instance	33
Insurance contract or identification number 00366 Number of Individuals Covered 55 Insurance policy start date 2009-09-01 Insurance policy end date 2010-08-31 Total amount of commissions paid to insurance broker USD $4,720 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $260,769 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	857515G
Policy instance	20
Insurance contract or identification number 857515G Number of Individuals Covered 28 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,688 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,439 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	851899G
Policy instance	19
Insurance contract or identification number 851899G Number of Individuals Covered 96 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $8,826 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $44,130 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	G000AC82
Policy instance	35
Insurance contract or identification number G000AC82 Number of Individuals Covered 23 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,301 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,503 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3727 & CP3727
Policy instance	4
Insurance contract or identification number CD3727 & CP3727 Number of Individuals Covered 7 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $369 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $4,809 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3723 & CD3724
Policy instance	5
Insurance contract or identification number CD3723 & CD3724 Number of Individuals Covered 47 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,470 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $30,694 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS6327
Policy instance	6
Insurance contract or identification number VS6327 Number of Individuals Covered 12 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $88 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $856 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	VS5269
Policy instance	7
Insurance contract or identification number VS5269 Number of Individuals Covered 17 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $161 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD0394 & CD0393
Policy instance	8
Insurance contract or identification number CD0394 & CD0393 Number of Individuals Covered 22 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $577 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $12,095 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	3721/3722/5262
Policy instance	9
Insurance contract or identification number 3721/3722/5262 Number of Individuals Covered 43 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,420 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,290 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )
Policy contract number	CD3735 & CD3736
Policy instance	11
Insurance contract or identification number CD3735 & CD3736 Number of Individuals Covered 32 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,380 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $20,011 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )
Policy contract number	SD26460001
Policy instance	12
Insurance contract or identification number SD26460001 Number of Individuals Covered 13 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $694 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,337 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	GVTL0133J
Policy instance	13
Insurance contract or identification number GVTL0133J Number of Individuals Covered 2 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $170 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $850 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	GVTL0951I
Policy instance	15
Insurance contract or identification number GVTL0951I Number of Individuals Covered 7 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $667 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,337 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number	1036221000
Policy instance	16
Insurance contract or identification number 1036221000 Number of Individuals Covered 115 Insurance policy start date 2009-07-01 Insurance policy end date 2010-06-30 Total amount of commissions paid to insurance broker USD $12,917 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )
Policy contract number	VS5268
Policy instance	17
Insurance contract or identification number VS5268 Number of Individuals Covered 4 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $47 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $483 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )
Policy contract number	64557
Policy instance	34
Insurance contract or identification number 64557 Number of Individuals Covered 7 Insurance policy start date 2009-09-01 Insurance policy end date 2010-08-31 Total amount of commissions paid to insurance broker USD $3,710 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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