401k Plan data: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN plan

COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN
Plan identification number	503

COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

COMMUNITYCARE HMO, INC. has sponsored the creation of one or more 401k plans.

Company Name: COMMUNITYCARE HMO, INC.

Employer identification number (EIN): 731433979

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-01-01 CHUCK GREER 2023-10-10
503 2021-01-01 CHUCK GREER 2022-10-10
503 2020-01-01 CHUCK GREER 2021-07-28
503 2019-01-01 CHUCK GREER 2020-10-05
503 2018-01-01 RYAN CRAWFORD 2019-09-03
503 2017-01-01
503 2016-01-01
503 2015-01-01
503 2014-01-01
503 2013-01-01 CANDIA L FIELDS
503 2012-01-01 CANDIA L FIELDS
503 2011-01-01 CANDIA L FIELDS
503 2009-01-01 CANDIA L FIELDS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
503	2022-01-01	CHUCK GREER	2023-10-10
503	2021-01-01	CHUCK GREER	2022-10-10
503	2020-01-01	CHUCK GREER	2021-07-28
503	2019-01-01	CHUCK GREER	2020-10-05
503	2018-01-01	RYAN CRAWFORD	2019-09-03
503	2017-01-01
503	2016-01-01
503	2015-01-01
503	2014-01-01
503	2013-01-01	CANDIA L FIELDS
503	2012-01-01	CANDIA L FIELDS
503	2011-01-01	CANDIA L FIELDS
503	2009-01-01	CANDIA L FIELDS

Plan Statistics for COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN

Measure Date Value
2022: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 432
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 441
Total of all active and inactive participants 2022-01-01 441
Total participants 2022-01-01 0
2021: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 402
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 432
Total of all active and inactive participants 2021-01-01 432
Total participants 2021-01-01 0
2020: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 417
Number of retired or separated participants receiving benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
Total participants 2020-01-01 0
2019: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 425
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 407
Total of all active and inactive participants 2019-01-01 407
Total participants 2019-01-01 407
2018: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 453
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 425
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 2018-01-01 425
Total participants 2018-01-01 425
2017: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 459
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 457
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 2017-01-01 457
Total participants 2017-01-01 457
2016: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 461
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 459
Total of all active and inactive participants 2016-01-01 459
Total participants 2016-01-01 459
2015: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 456
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 461
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 2015-01-01 461
Total participants 2015-01-01 461
2014: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 462
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 456
Total of all active and inactive participants 2014-01-01 456
Total participants 2014-01-01 456
2013: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 426
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 456
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 2013-01-01 456
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 456
Number of participants with account balances 2013-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 426
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 428
Total of all active and inactive participants 2012-01-01 428
Total participants 2012-01-01 428
2011: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 445
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 433
Total of all active and inactive participants 2011-01-01 433
Total participants 2011-01-01 433
2009: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 450
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 443
Total of all active and inactive participants 2009-01-01 443
Total participants 2009-01-01 443

Measure	Date	Value
2022: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	432
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	441
Total of all active and inactive participants	2022-01-01	441
Total participants	2022-01-01	0
2021: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	402
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	432
Total of all active and inactive participants	2021-01-01	432
Total participants	2021-01-01	0
2020: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	417
Number of retired or separated participants receiving benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
Total participants	2020-01-01	0
2019: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	425
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	407
Total of all active and inactive participants	2019-01-01	407
Total participants	2019-01-01	407
2018: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	453
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	425
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	425
Total participants	2018-01-01	425
2017: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	459
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	457
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	457
Total participants	2017-01-01	457
2016: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	461
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	459
Total of all active and inactive participants	2016-01-01	459
Total participants	2016-01-01	459
2015: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	456
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	461
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	461
Total participants	2015-01-01	461
2014: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	462
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	456
Total of all active and inactive participants	2014-01-01	456
Total participants	2014-01-01	456
2013: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	426
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	456
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	456
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	456
Number of participants with account balances	2013-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	426
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	428
Total of all active and inactive participants	2012-01-01	428
Total participants	2012-01-01	428
2011: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	445
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	433
Total of all active and inactive participants	2011-01-01	433
Total participants	2011-01-01	433
2009: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	450
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	443
Total of all active and inactive participants	2009-01-01	443
Total participants	2009-01-01	443

Form 5500 Responses for COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN

2022: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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 benefit arrangement – Insurance	Yes
2020: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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: COMMUNITYCARE HMO, INC. WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: COMMUNITYCARE HMO, INC. WELFARE BENEFITS 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

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	442
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,952
Total amount of fees paid to insurance company	USD $3,057
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $180,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3057
Additional information about fees paid to insurance broker	ADD'L COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $8,952

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5994007

Policy instance

Insurance contract or identification number	5994007
Number of Individuals Covered	1077
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,679
Total amount of fees paid to insurance company	USD $2,066
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $78,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,679
Amount paid for insurance broker fees	63
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	431
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,174
Total amount of fees paid to insurance company	USD $1,850
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $147,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $694
Insurance broker organization code?	3
Amount paid for insurance broker fees	1850
Additional information about fees paid to insurance broker	ADD'L COMPENSATION

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5994007

Policy instance

Insurance contract or identification number	5994007
Number of Individuals Covered	789
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $35,852
Total amount of fees paid to insurance company	USD $8,498
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $306,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4534
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $35,852

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	408
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $4,915
Total amount of fees paid to insurance company	USD $315
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,663
Insurance broker organization code?	3
Amount paid for insurance broker fees	315
Additional information about fees paid to insurance broker	ADD'L COMPENSATION

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5994007

Policy instance

Insurance contract or identification number	5994007
Number of Individuals Covered	775
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $36,160
Total amount of fees paid to insurance company	USD $4,268
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $204,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,160
Amount paid for insurance broker fees	4227
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5994007

Policy instance

Insurance contract or identification number	5994007
Number of Individuals Covered	840
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $23,254
Total amount of fees paid to insurance company	USD $1,147
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $214,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,197
Amount paid for insurance broker fees	1147
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	400
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,452
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,452
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	954
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $31,350
Total amount of fees paid to insurance company	USD $4,407
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $263,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,350
Amount paid for insurance broker fees	4407
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SUMMIT FINANCIAL GROUP INC

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	465
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,707
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,707
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY INC

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	461
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,374
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,374
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	785
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $22,206
Total amount of fees paid to insurance company	USD $3,308
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $197,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,775
Amount paid for insurance broker fees	3308
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NFP INS SERVICES INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	944
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $23,709
Total amount of fees paid to insurance company	USD $3,052
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $189,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,140
Amount paid for insurance broker fees	3052
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NFP INS SERVICES INC

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	453
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,442
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,442
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY INC

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	456
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,236
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,236
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	440
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $23,144
Total amount of fees paid to insurance company	USD $9,493
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $192,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,144
Amount paid for insurance broker fees	9493
Insurance broker organization code?	3
Insurance broker name	SUMMIT FINANCIAL GROUP INC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

DVE61

Policy instance

Insurance contract or identification number	DVE61
Number of Individuals Covered	106
Insurance policy start date	2013-01-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $5,472
Welfare Benefit Premiums Paid to Carrier	USD $45,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,548
Insurance broker organization code?	3
Insurance broker name	JOHN A. WILLIAMS COMPANY INC.

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	421
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $6,253
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,253
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY, INC.

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	195
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Other welfare benefits provided	ACCIDENTAL DISMEM. (VOL.)
Welfare Benefit Premiums Paid to Carrier	USD $4,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	420
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

DVE61

Policy instance

Insurance contract or identification number	DVE61
Number of Individuals Covered	106
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $26,957
Total amount of fees paid to insurance company	USD $1,826
Welfare Benefit Premiums Paid to Carrier	USD $105,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,182
Amount paid for insurance broker fees	1522
Insurance broker organization code?	3
Insurance broker name	DANNY W SMITH

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	428
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,225
Total amount of fees paid to insurance company	USD $4,044
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,225
Amount paid for insurance broker fees	4044
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SUMMITT FINANCIAL GROUP INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05994007

Policy instance

Insurance contract or identification number	KM05994007
Number of Individuals Covered	428
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $178
Total amount of fees paid to insurance company	USD $83
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEM.
Welfare Benefit Premiums Paid to Carrier	USD $3,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $178
Amount paid for insurance broker fees	83
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SUMMIT FINANCIAL GROUP INC

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	255
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	420
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEM. (BASIC)
Welfare Benefit Premiums Paid to Carrier	USD $8,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

DVE61

Policy instance

Insurance contract or identification number	DVE61
Number of Individuals Covered	148
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $28,492
Total amount of fees paid to insurance company	USD $2,064
Welfare Benefit Premiums Paid to Carrier	USD $71,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	199
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Other welfare benefits provided	ACCIDENTAL DISMEM. (VOL.)
Welfare Benefit Premiums Paid to Carrier	USD $7,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	269
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	424
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEM. (BASIC)
Welfare Benefit Premiums Paid to Carrier	USD $14,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	424
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	420
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $6,215
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	433
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEM. (BASIC)
Welfare Benefit Premiums Paid to Carrier	USD $14,060

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

Policy contract number

103604

Policy instance

Insurance contract or identification number	103604
Number of Individuals Covered	441
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $6,162
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,552
Commission paid to Insurance Broker	USD $6,162
Insurance broker organization code?	3
Insurance broker name	JIM RULEY & COMPANY, INC.

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	433
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,171

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	199
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DISMEM. (VOL.)
Welfare Benefit Premiums Paid to Carrier	USD $7,606

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

G-25960

Policy instance

Insurance contract or identification number	G-25960
Number of Individuals Covered	269
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,683

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Company Name:	COMMUNITYCARE HMO, INC.
Employer identification number (EIN):	731433979
NAIC Classification:	524140