401k Plan data: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN plan

MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 401k Plan overview

Plan Name	MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN
Plan identification number	502

MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN Benefits

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

401k Sponsoring company profile

MILL CREEK LUMBER & SUPPLY CO. has sponsored the creation of one or more 401k plans.

Company Name: MILL CREEK LUMBER & SUPPLY CO.

Employer identification number (EIN): 730541869

NAIC Classification: 444190
NAIC Description: Other Building Material Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01
502 2021-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01
502 2017-01-01 JEFFREY DUNN
502 2016-01-01 JEFFREY DUNN
502 2015-01-01 JEFFREY DUNN
502 2014-01-01 JEFFREY DUNN
502 2013-01-01 JEFFREY DUNN
502 2012-01-01 JEFFREY DUNN
502 2011-01-01 JEFFREY DUNN
502 2010-01-01 JEFFREY DUNN
502 2009-01-01 JEFFREY DUNN

Plan Statistics for MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN

401k plan membership statisitcs for MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN

Measure Date Value
2022: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 674
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 795
Total of all active and inactive participants 2022-01-01 795
2021: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 654
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 674
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 674
2020: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 616
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 654
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 654
2019: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 663
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 616
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 616
2018: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 692
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 663
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 663
2017: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 681
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 692
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 692
2016: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 681
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 681
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 681
2015: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 319
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 681
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 681
2014: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 346
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 319
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 319
2013: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 346
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 346
2012: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 292
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 273
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 273
2011: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 335
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 292
Number of retired or separated participants receiving benefits 2011-01-01 2
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 294
2010: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 351
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 335
Number of retired or separated participants receiving benefits 2010-01-01 2
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 337
2009: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 381
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 351
Number of retired or separated participants receiving benefits 2009-01-01 7
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 358

Measure	Date	Value
2022: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	674
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	795
Total of all active and inactive participants	2022-01-01	795
2021: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	654
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	674
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	674
2020: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	616
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	654
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	654
2019: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	663
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	616
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	616
2018: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	692
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	663
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	663
2017: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	681
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	692
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	692
2016: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	681
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	681
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	681
2015: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	319
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	681
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	681
2014: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	346
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	319
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	319
2013: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	346
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	346
2012: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	292
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	273
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	273
2011: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	335
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	292
Number of retired or separated participants receiving benefits	2011-01-01	2
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	294
2010: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	351
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	335
Number of retired or separated participants receiving benefits	2010-01-01	2
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	337
2009: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	381
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	351
Number of retired or separated participants receiving benefits	2009-01-01	7
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	358

Form 5500 Responses for MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN

2022: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE 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
2010: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: MILL CREEK LUMBER & SUPPLY COMPANY EMPLOYEE HEALTH CARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	401
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,145
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 $69,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,145

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

02111

Policy instance

Insurance contract or identification number	02111
Number of Individuals Covered	116
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,496
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
Other welfare benefits provided	CANCER
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 $36,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,495
Insurance broker organization code?	3

WEX INC. (National Association of Insurance Commissioners NAIC id number: 56199 )

Policy contract number

38531

Policy instance

Insurance contract or identification number	38531
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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	COBRA
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 $12,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

MILL CREEK

Policy instance

Insurance contract or identification number	MILL CREEK
Number of Individuals Covered	795
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,921

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

Policy contract number

000VY878

Policy instance

Insurance contract or identification number	000VY878
Number of Individuals Covered	199
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,023
Total amount of fees paid to insurance company	USD $358
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 $34,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,023
Amount paid for insurance broker fees	358
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

Policy instance

Number of Individuals Covered	479
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $139,632
Total amount of fees paid to insurance company	USD $201,548
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 $593,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $139,632
Amount paid for insurance broker fees	201548
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	305
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,462
Total amount of fees paid to insurance company	USD $1,892
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $116,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,462
Amount paid for insurance broker fees	1892
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	188
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,764
Total amount of fees paid to insurance company	USD $1,034
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 $65,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,764
Amount paid for insurance broker fees	1034
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	248
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,326
Total amount of fees paid to insurance company	USD $700
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 $42,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,326
Amount paid for insurance broker fees	700
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	674
Insurance policy start date	2021-01-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $4,635
Total amount of fees paid to insurance company	USD $18,540
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 $4,635
Amount paid for insurance broker fees	18540
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	356
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,978
Vision 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 $1,261
Additional information about fees paid to insurance broker	VISION CARE
Insurance broker organization code?	3

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

Policy contract number

00543003

Policy instance

Insurance contract or identification number	00543003
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $13,895
Total amount of fees paid to insurance company	USD $681
Dental 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 $10,146
Insurance broker organization code?	3
Amount paid for insurance broker fees	681
Additional information about fees paid to insurance broker	DENTAL CARE

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

Policy contract number

00543005

Policy instance

Insurance contract or identification number	00543005
Number of Individuals Covered	250
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,298
Total amount of fees paid to insurance company	USD $730
Dental 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 $11,169
Amount paid for insurance broker fees	730
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

02111

Policy instance

Insurance contract or identification number	02111
Number of Individuals Covered	128
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,970
Total amount of fees paid to insurance company	USD $56
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $44,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,288
Amount paid for insurance broker fees	56
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

Policy instance

Number of Individuals Covered	421
Insurance policy start date	2021-10-01
Insurance policy end date	2021-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	328
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,307
Life 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 $15,673
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	219
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,888
Long Term Disability 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 $8,306
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166171

Policy instance

Insurance contract or identification number	166171
Number of Individuals Covered	286
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,304
Temporary Disability 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 $5,818
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	654
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,946
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 $3,946
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

00543003

Policy instance

Insurance contract or identification number	00543003
Number of Individuals Covered	197
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,009
Total amount of fees paid to insurance company	USD $1,209
Dental 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 $15,009
Amount paid for insurance broker fees	1209
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	331
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,888
Vision 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 $1,888
Additional information about fees paid to insurance broker	VISION CARE
Insurance broker organization code?	3

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

Policy contract number

00543005

Policy instance

Insurance contract or identification number	00543005
Number of Individuals Covered	217
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,078
Total amount of fees paid to insurance company	USD $1,538
Dental 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 $16,078
Amount paid for insurance broker fees	1538
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

02111

Policy instance

Insurance contract or identification number	02111
Number of Individuals Covered	115
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,877
Total amount of fees paid to insurance company	USD $365
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $36,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,877
Amount paid for insurance broker fees	365
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	616
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $25,526
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 $25,526
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT PPP ENGAGEMENT CREDIT MED RETENTION
Insurance broker organization code?	3

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

Policy contract number

00543005

Policy instance

Insurance contract or identification number	00543005
Number of Individuals Covered	208
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,592
Total amount of fees paid to insurance company	USD $1,840
Dental 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 $16,592
Amount paid for insurance broker fees	1840
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

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

Policy contract number

00543003

Policy instance

Insurance contract or identification number	00543003
Number of Individuals Covered	180
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,025
Total amount of fees paid to insurance company	USD $1,294
Dental 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 $13,025
Amount paid for insurance broker fees	1294
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	301
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,712
Vision 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 $1,712
Additional information about fees paid to insurance broker	VISION CARE
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00543003

Policy instance

Insurance contract or identification number	00543003
Number of Individuals Covered	178
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,683
Dental 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 $12,683
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

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

Policy contract number

00543005

Policy instance

Insurance contract or identification number	00543005
Number of Individuals Covered	209
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $18,045
Dental 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 $18,045
Additional information about fees paid to insurance broker	DENTAL CARE
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	663
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $37,192
Total amount of fees paid to insurance company	USD $6,410
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability 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 $37,192
Amount paid for insurance broker fees	6410
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT PPP ENGAGEMENT CREDIT MED RETENTION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,751
Vision 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 $1,751
Additional information about fees paid to insurance broker	VISION CARE
Insurance broker organization code?	3

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

MILL CREEK

Policy instance

Insurance contract or identification number	MILL CREEK
Number of Individuals Covered	380
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30052998

Policy instance

Insurance contract or identification number	30052998
Number of Individuals Covered	273
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,736
Vision 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 $1,736
Additional information about fees paid to insurance broker	VISION CARE
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LIMITED

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	692
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $54,885
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	S/T DISABILITY & ACCIDENTAL DEATH &
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,123
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LIMITED

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847799

Policy instance

Insurance contract or identification number	0847799
Number of Individuals Covered	681
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $42,451
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,451
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPROA14E

Policy instance

Insurance contract or identification number	GUPROA14E
Number of Individuals Covered	135
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,726
Total amount of fees paid to insurance company	USD $1,161
Long Term Disability 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 $7,726
Amount paid for insurance broker fees	1161
Additional information about fees paid to insurance broker	BROKERAGE OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

MILL CREEK

Policy instance

Insurance contract or identification number	MILL CREEK
Number of Individuals Covered	380
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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

GVTL0A14E

Policy instance

Insurance contract or identification number	GVTL0A14E
Number of Individuals Covered	229
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $17,131
Total amount of fees paid to insurance company	USD $2,571
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,131
Amount paid for insurance broker fees	2571
Additional information about fees paid to insurance broker	BROKERAGE OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0A14E

Policy instance

Insurance contract or identification number	GUC0A14E
Number of Individuals Covered	175
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,490
Total amount of fees paid to insurance company	USD $524
Temporary Disability 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 $3,490
Amount paid for insurance broker fees	524
Additional information about fees paid to insurance broker	BROKERAGE OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

753676

Policy instance

Insurance contract or identification number	753676
Number of Individuals Covered	577
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,498
Total amount of fees paid to insurance company	USD $55,538
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 $5,498
Amount paid for insurance broker fees	55538
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

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

Policy contract number

753676

Policy instance

Insurance contract or identification number	753676
Number of Individuals Covered	643
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $65,182
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 $65,182
Additional information about fees paid to insurance broker	BROKERAGE
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0A14E

Policy instance

Insurance contract or identification number	GUC0A14E
Number of Individuals Covered	188
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,672
Life 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 $3,672
Insurance broker organization code?	3
Insurance broker name

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0A14E

Policy instance

Insurance contract or identification number	GVTL0A14E
Number of Individuals Covered	258
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,284
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,284
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPROA14E

Policy instance

Insurance contract or identification number	GUPROA14E
Number of Individuals Covered	151
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,953
Long Term Disability 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 $7,953
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

C01209

Policy instance

Insurance contract or identification number	C01209
Number of Individuals Covered	504
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $38,201
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 $38,201
Additional information about fees paid to insurance broker	BROKERAGE
Insurance broker name	HOLMES ORGANIZATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPROA14E

Policy instance

Insurance contract or identification number	GUPROA14E
Number of Individuals Covered	139
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,833
Long Term Disability 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 $7,833
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0A14E

Policy instance

Insurance contract or identification number	GVTL0A14E
Number of Individuals Covered	228
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $17,520
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,520
Insurance broker organization code?	3
Insurance broker name	HOLMES ORGANIZATION INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0A14E

Policy instance

Insurance contract or identification number	GUC0A14E
Number of Individuals Covered	163
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,821
Life 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 $3,821
Insurance broker organization code?	3
Insurance broker name

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

MILL CREEK

Policy instance

Insurance contract or identification number	MILL CREEK
Number of Individuals Covered	380
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

MILL CREEK

Policy instance

Insurance contract or identification number	MILL CREEK
Number of Individuals Covered	380
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?	No

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

C01209

Policy instance

Insurance contract or identification number	C01209
Number of Individuals Covered	511
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,983
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

5103640000

Policy instance

Insurance contract or identification number	5103640000
Number of Individuals Covered	640
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $59,118
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	MILL CREEK LUMBER & SUPPLY CO.
Employer identification number (EIN):	730541869
NAIC Classification:	444190
NAIC Description:	Other Building Material Dealers