401k Plan data: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN plan

COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN
Plan identification number	501

COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

COMMUNITY SERVICES OFFICE, INC. has sponsored the creation of one or more 401k plans.

Company Name: COMMUNITY SERVICES OFFICE, INC.

Employer identification number (EIN): 710389282

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-11-01
501 2021-11-01
501 2020-11-01
501 2019-11-01
501 2018-11-01

Plan Statistics for COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-11-01 121
Total number of active participants reported on line 7a of the Form 5500 2022-11-01 261
Number of retired or separated participants receiving benefits 2022-11-01 0
Number of other retired or separated participants entitled to future benefits 2022-11-01 0
Total of all active and inactive participants 2022-11-01 261
2021: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-11-01 112
Total number of active participants reported on line 7a of the Form 5500 2021-11-01 121
Number of retired or separated participants receiving benefits 2021-11-01 0
Number of other retired or separated participants entitled to future benefits 2021-11-01 0
Total of all active and inactive participants 2021-11-01 121
2020: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-11-01 104
Total number of active participants reported on line 7a of the Form 5500 2020-11-01 111
Number of retired or separated participants receiving benefits 2020-11-01 0
Number of other retired or separated participants entitled to future benefits 2020-11-01 0
Total of all active and inactive participants 2020-11-01 111
2019: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-11-01 102
Total number of active participants reported on line 7a of the Form 5500 2019-11-01 104
Number of retired or separated participants receiving benefits 2019-11-01 0
Number of other retired or separated participants entitled to future benefits 2019-11-01 0
Total of all active and inactive participants 2019-11-01 104
2018: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-11-01 60
Total number of active participants reported on line 7a of the Form 5500 2018-11-01 102
Number of retired or separated participants receiving benefits 2018-11-01 1
Number of other retired or separated participants entitled to future benefits 2018-11-01 1
Total of all active and inactive participants 2018-11-01 104

Measure	Date	Value
2022: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-11-01	121
Total number of active participants reported on line 7a of the Form 5500	2022-11-01	261
Number of retired or separated participants receiving benefits	2022-11-01	0
Number of other retired or separated participants entitled to future benefits	2022-11-01	0
Total of all active and inactive participants	2022-11-01	261
2021: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-11-01	112
Total number of active participants reported on line 7a of the Form 5500	2021-11-01	121
Number of retired or separated participants receiving benefits	2021-11-01	0
Number of other retired or separated participants entitled to future benefits	2021-11-01	0
Total of all active and inactive participants	2021-11-01	121
2020: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-11-01	104
Total number of active participants reported on line 7a of the Form 5500	2020-11-01	111
Number of retired or separated participants receiving benefits	2020-11-01	0
Number of other retired or separated participants entitled to future benefits	2020-11-01	0
Total of all active and inactive participants	2020-11-01	111
2019: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-11-01	102
Total number of active participants reported on line 7a of the Form 5500	2019-11-01	104
Number of retired or separated participants receiving benefits	2019-11-01	0
Number of other retired or separated participants entitled to future benefits	2019-11-01	0
Total of all active and inactive participants	2019-11-01	104
2018: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-11-01	60
Total number of active participants reported on line 7a of the Form 5500	2018-11-01	102
Number of retired or separated participants receiving benefits	2018-11-01	1
Number of other retired or separated participants entitled to future benefits	2018-11-01	1
Total of all active and inactive participants	2018-11-01	104

Form 5500 Responses for COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN

2022: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-11-01	Type of plan entity	Single employer plan
2022-11-01	Submission has been amended	No
2022-11-01	This submission is the final filing	No
2022-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-11-01	Plan is a collectively bargained plan	No
2022-11-01	Plan funding arrangement – Insurance	Yes
2022-11-01	Plan benefit arrangement – Insurance	Yes
2021: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-11-01	Type of plan entity	Single employer plan
2021-11-01	Submission has been amended	No
2021-11-01	This submission is the final filing	No
2021-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-11-01	Plan is a collectively bargained plan	No
2021-11-01	Plan funding arrangement – Insurance	Yes
2021-11-01	Plan benefit arrangement – Insurance	Yes
2020: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-11-01	Type of plan entity	Single employer plan
2020-11-01	Submission has been amended	No
2020-11-01	This submission is the final filing	No
2020-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-11-01	Plan is a collectively bargained plan	No
2020-11-01	Plan funding arrangement – Insurance	Yes
2020-11-01	Plan benefit arrangement – Insurance	Yes
2019: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-11-01	Type of plan entity	Single employer plan
2019-11-01	Submission has been amended	No
2019-11-01	This submission is the final filing	No
2019-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-11-01	Plan is a collectively bargained plan	No
2019-11-01	Plan funding arrangement – Insurance	Yes
2019-11-01	Plan benefit arrangement – Insurance	Yes
2018: COMMUNITY SERVICES OFFICE, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-11-01	Type of plan entity	Single employer plan
2018-11-01	First time form 5500 has been submitted	Yes
2018-11-01	Submission has been amended	No
2018-11-01	This submission is the final filing	No
2018-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-11-01	Plan is a collectively bargained plan	No
2018-11-01	Plan funding arrangement – Insurance	Yes
2018-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	17
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,024
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $731
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	261
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $3,726
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,445
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	259
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $3,871
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $35,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,579
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30036518

Policy instance

Insurance contract or identification number	30036518
Number of Individuals Covered	42
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $688
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $344
Insurance broker organization code?	3

ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )

Policy contract number

017698

Policy instance

Insurance contract or identification number	017698
Number of Individuals Covered	53
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $2,531
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,531
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

773059

Policy instance

Insurance contract or identification number	773059
Number of Individuals Covered	33
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $9,683
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,683
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	82
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,293
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY TERM LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $923
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	41
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $162
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $772
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
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30036518

Policy instance

Insurance contract or identification number	30036518
Number of Individuals Covered	40
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $520
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $260
Insurance broker organization code?	3

ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )

Policy contract number

017698

Policy instance

Insurance contract or identification number	017698
Number of Individuals Covered	47
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $2,601
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,601
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

773059

Policy instance

Insurance contract or identification number	773059
Number of Individuals Covered	32
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $9,200
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,200
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	36
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $1,020
Total amount of fees paid to insurance company	USD $16
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY TERM LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $728
Amount paid for insurance broker fees	16
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	18
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $164
Total amount of fees paid to insurance company	USD $2
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $117
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	10
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $1,198
Total amount of fees paid to insurance company	USD $3
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $856
Amount paid for insurance broker fees	3
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	119
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $3,737
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,454
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	121
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $3,733
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,451
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

773059

Policy instance

Insurance contract or identification number	773059
Number of Individuals Covered	36
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $11,247
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,247
Insurance broker organization code?	3

ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )

Policy contract number

017698

Policy instance

Insurance contract or identification number	017698
Number of Individuals Covered	44
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $2,846
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,846
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30036518

Policy instance

Insurance contract or identification number	30036518
Number of Individuals Covered	40
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $594
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $297
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	111
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $2,936
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,693
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	112
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $2,512
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,305
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	104
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $2,825
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,598
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	103
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $3,265
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,005
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30036518

Policy instance

Insurance contract or identification number	30036518
Number of Individuals Covered	53
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $750
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $375
Insurance broker organization code?	3

ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )

Policy contract number

017698

Policy instance

Insurance contract or identification number	017698
Number of Individuals Covered	77
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $3,979
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,979
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

773059

Policy instance

Insurance contract or identification number	773059
Number of Individuals Covered	48
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $12,788
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,788
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

773059

Policy instance

Insurance contract or identification number	773059
Number of Individuals Covered	46
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $10,603
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,603
Insurance broker organization code?	3

ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )

Policy contract number

017698

Policy instance

Insurance contract or identification number	017698
Number of Individuals Covered	62
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $2,349
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,349
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30036518

Policy instance

Insurance contract or identification number	30036518
Number of Individuals Covered	46
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $287
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	102
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $2,367
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174
Insurance broker organization code?	3

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

Policy contract number

50004005

Policy instance

Insurance contract or identification number	50004005
Number of Individuals Covered	102
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $2,201
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,010
Insurance broker organization code?	3

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Company Name:	COMMUNITY SERVICES OFFICE, INC.
Employer identification number (EIN):	710389282
NAIC Classification:	624100
NAIC Description:	Individual and Family Services