401k Plan data: THE GILLMAN COMPANIES CAFETERIA PLAN plan

THE GILLMAN COMPANIES CAFETERIA PLAN 401k Plan overview

Plan Name	THE GILLMAN COMPANIES CAFETERIA PLAN
Plan identification number	502

THE GILLMAN COMPANIES CAFETERIA 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

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

Company Name: GILLMAN SERVICES, INC.

Employer identification number (EIN): 741597662

NAIC Classification: 441110
NAIC Description: New Car Dealers

Additional information about GILLMAN SERVICES, INC.

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 2008-05-27

Company Identification Number: 0695232

Legal Registered Office Address: 11848 ROCK LANDING DR SUITE 102
SUITE 102
NEWPORT NEWS
United States of America (USA)
23606

More information about GILLMAN SERVICES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE GILLMAN COMPANIES CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2023-01-01
502 2022-01-01
502 2021-01-01
502 2020-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01 BART MCANDREWS
502 2017-01-01 BART MCANDREWS
502 2016-01-01
502 2015-01-01
502 2014-01-01
502 2013-01-01
502 2012-01-01 BART MCANDREWS
502 2011-01-01 BART MCANDREWS

Plan Statistics for THE GILLMAN COMPANIES CAFETERIA PLAN

401k plan membership statisitcs for THE GILLMAN COMPANIES CAFETERIA PLAN

Measure Date Value
2023: THE GILLMAN COMPANIES CAFETERIA PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 782
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 779
Number of retired or separated participants receiving benefits 2023-01-01 1
Number of other retired or separated participants entitled to future benefits 2023-01-01 9
Total of all active and inactive participants 2023-01-01 789
2022: THE GILLMAN COMPANIES CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 800
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 781
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 35
Total of all active and inactive participants 2022-01-01 817
2021: THE GILLMAN COMPANIES CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 772
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 793
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 33
Total of all active and inactive participants 2021-01-01 828
2020: THE GILLMAN COMPANIES CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 820
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 770
Number of retired or separated participants receiving benefits 2020-01-01 4
Number of other retired or separated participants entitled to future benefits 2020-01-01 42
Total of all active and inactive participants 2020-01-01 816
2019: THE GILLMAN COMPANIES CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 796
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 768
Number of retired or separated participants receiving benefits 2019-01-01 6
Number of other retired or separated participants entitled to future benefits 2019-01-01 45
Total of all active and inactive participants 2019-01-01 819
2018: THE GILLMAN COMPANIES CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 770
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 766
Number of retired or separated participants receiving benefits 2018-01-01 3
Number of other retired or separated participants entitled to future benefits 2018-01-01 29
Total of all active and inactive participants 2018-01-01 798
2017: THE GILLMAN COMPANIES CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 730
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 711
Number of retired or separated participants receiving benefits 2017-01-01 5
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 716
2016: THE GILLMAN COMPANIES CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 508
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 682
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 5
Total of all active and inactive participants 2016-01-01 687
2015: THE GILLMAN COMPANIES CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 505
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 505
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 3
Total of all active and inactive participants 2015-01-01 508
2014: THE GILLMAN COMPANIES CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 415
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 503
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 2
Total of all active and inactive participants 2014-01-01 505
2013: THE GILLMAN COMPANIES CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 408
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 415
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 2013-01-01 415
2012: THE GILLMAN COMPANIES CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 421
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 408
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 2012-01-01 408
2011: THE GILLMAN COMPANIES CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 418
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 421
Total of all active and inactive participants 2011-01-01 421
Total participants 2011-01-01 421

Measure	Date	Value
2023: THE GILLMAN COMPANIES CAFETERIA PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	782
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	779
Number of retired or separated participants receiving benefits	2023-01-01	1
Number of other retired or separated participants entitled to future benefits	2023-01-01	9
Total of all active and inactive participants	2023-01-01	789
2022: THE GILLMAN COMPANIES CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	800
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	781
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	35
Total of all active and inactive participants	2022-01-01	817
2021: THE GILLMAN COMPANIES CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	772
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	793
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	33
Total of all active and inactive participants	2021-01-01	828
2020: THE GILLMAN COMPANIES CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	820
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	770
Number of retired or separated participants receiving benefits	2020-01-01	4
Number of other retired or separated participants entitled to future benefits	2020-01-01	42
Total of all active and inactive participants	2020-01-01	816
2019: THE GILLMAN COMPANIES CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	796
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	768
Number of retired or separated participants receiving benefits	2019-01-01	6
Number of other retired or separated participants entitled to future benefits	2019-01-01	45
Total of all active and inactive participants	2019-01-01	819
2018: THE GILLMAN COMPANIES CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	770
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	766
Number of retired or separated participants receiving benefits	2018-01-01	3
Number of other retired or separated participants entitled to future benefits	2018-01-01	29
Total of all active and inactive participants	2018-01-01	798
2017: THE GILLMAN COMPANIES CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	730
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	711
Number of retired or separated participants receiving benefits	2017-01-01	5
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	716
2016: THE GILLMAN COMPANIES CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	508
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	682
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	5
Total of all active and inactive participants	2016-01-01	687
2015: THE GILLMAN COMPANIES CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	505
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	505
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	3
Total of all active and inactive participants	2015-01-01	508
2014: THE GILLMAN COMPANIES CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	503
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	2
Total of all active and inactive participants	2014-01-01	505
2013: THE GILLMAN COMPANIES CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	408
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	415
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	415
2012: THE GILLMAN COMPANIES CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	421
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	408
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	408
2011: THE GILLMAN COMPANIES CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	418
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	421
Total of all active and inactive participants	2011-01-01	421
Total participants	2011-01-01	421

Form 5500 Responses for THE GILLMAN COMPANIES CAFETERIA PLAN

2023: THE GILLMAN COMPANIES CAFETERIA PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	No
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: THE GILLMAN COMPANIES CAFETERIA 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: THE GILLMAN COMPANIES CAFETERIA PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: THE GILLMAN COMPANIES CAFETERIA PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THE GILLMAN COMPANIES CAFETERIA PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
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: THE GILLMAN COMPANIES CAFETERIA PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: THE GILLMAN COMPANIES CAFETERIA PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: THE GILLMAN COMPANIES CAFETERIA 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 funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926520

Policy instance

Insurance contract or identification number	926520
Number of Individuals Covered	804
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $26,867
Total amount of fees paid to insurance company	USD $808
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $213,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,867
Insurance broker organization code?	3
Amount paid for insurance broker fees	808
Additional information about fees paid to insurance broker	BONUS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926547

Policy instance

Insurance contract or identification number	926547
Number of Individuals Covered	792
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $24,214
Total amount of fees paid to insurance company	USD $1,661
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $281,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,874
Insurance broker organization code?	3
Amount paid for insurance broker fees	1661
Additional information about fees paid to insurance broker	BONUS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926520

Policy instance

Insurance contract or identification number	926520
Number of Individuals Covered	840
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $6,147
Total amount of fees paid to insurance company	USD $622
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,147
Insurance broker organization code?	3
Amount paid for insurance broker fees	622
Additional information about fees paid to insurance broker	BONUS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926547

Policy instance

Insurance contract or identification number	926547
Number of Individuals Covered	349
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $7,049
Total amount of fees paid to insurance company	USD $1,284
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 $169,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,372
Insurance broker organization code?	3
Amount paid for insurance broker fees	1284
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	435
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $5,930
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 $47,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,930
Insurance broker organization code?	3

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	268
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $31,491
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $157,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,491
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	193
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $36,464
Total amount of fees paid to insurance company	USD $1,880
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
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL INDEMNITY
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 $283,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,464
Amount paid for insurance broker fees	1880
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	335
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $46,217
Total amount of fees paid to insurance company	USD $203
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
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL INDEMNITY
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 $310,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,217
Amount paid for insurance broker fees	203
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	257
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $28,255
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $141,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,255
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926547

Policy instance

Insurance contract or identification number	926547
Number of Individuals Covered	320
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $6,434
Total amount of fees paid to insurance company	USD $445
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 $160,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,003
Insurance broker organization code?	3
Amount paid for insurance broker fees	445
Additional information about fees paid to insurance broker	BONUS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926520

Policy instance

Insurance contract or identification number	926520
Number of Individuals Covered	840
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $7,379
Total amount of fees paid to insurance company	USD $206
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,379
Insurance broker organization code?	3
Amount paid for insurance broker fees	206
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

0729280

Policy instance

Insurance contract or identification number	0729280
Number of Individuals Covered	432
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $4,713
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 $37,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,713
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	423
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $53,392
Total amount of fees paid to insurance company	USD $1,756
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
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL INDEMNITY
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 $317,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,392
Amount paid for insurance broker fees	1756
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	287
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $29,008
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $145,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,008
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926547

Policy instance

Insurance contract or identification number	926547
Number of Individuals Covered	318
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $7,058
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $168,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,959
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

926520

Policy instance

Insurance contract or identification number	926520
Number of Individuals Covered	837
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $5,182
Total amount of fees paid to insurance company	USD $1,632
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $41,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,182
Insurance broker organization code?	3
Amount paid for insurance broker fees	1632
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	721
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
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 $52,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0729280

Policy instance

Insurance contract or identification number	0729280
Number of Individuals Covered	405
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $5,209
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 $52,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,209
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109*

Policy instance

Insurance contract or identification number	E3367109*
Number of Individuals Covered	237
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $48,969
Total amount of fees paid to insurance company	USD $1,554
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
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL INDEMNITY
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 $308,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,969
Amount paid for insurance broker fees	1554
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	268
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $22,731
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $113,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,731
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	786
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $19,524
Total amount of fees paid to insurance company	USD $1,299
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $175,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,524
Amount paid for insurance broker fees	1299
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS PAID
Insurance broker organization code?	3

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	166
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $3,041
Total amount of fees paid to insurance company	USD $247
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 $30,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,041
Amount paid for insurance broker fees	247
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS PAID
Insurance broker organization code?	3

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	730
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	448
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $5,186
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 $52,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,186
Insurance broker organization code?	3

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	177
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $3,346
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,346
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	752
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $15,199
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $141,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,199
Insurance broker organization code?	3

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	274
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $20,678
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $103,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,678
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109*

Policy instance

Insurance contract or identification number	E3367109*
Number of Individuals Covered	234
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $52,791
Total amount of fees paid to insurance company	USD $1,334
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
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
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 $343,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,791
Amount paid for insurance broker fees	1334
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109*

Policy instance

Insurance contract or identification number	E3367109*
Number of Individuals Covered	231
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $71,468
Total amount of fees paid to insurance company	USD $2,129
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 $430,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,468
Amount paid for insurance broker fees	2129
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	VARIOUS AGENTS / ADDRESS UNKNOWN

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	259
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $17,310
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $86,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,310
Insurance broker organization code?	3
Insurance broker name	ROBERT J HUMPHREY

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	763
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $19,195
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $148,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,195
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TEXAS INC

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5475198

Policy instance

Insurance contract or identification number	5475198
Number of Individuals Covered	184
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $4,205
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,205
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TEXAS INC

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	696
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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 $60,398
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

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	271
Insurance policy start date	2014-03-01
Insurance policy end date	2015-03-01
Total amount of commissions paid to insurance broker	USD $16,444
Total amount of fees paid to insurance company	USD $648
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,444
Amount paid for insurance broker fees	648
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	282
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $54,491
Total amount of fees paid to insurance company	USD $6,679
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $265,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,491
Amount paid for insurance broker fees	6679
Additional information about fees paid to insurance broker	BROKER/CONSULTANT BONUS.
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109

Policy instance

Insurance contract or identification number	E3367109
Number of Individuals Covered	55
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $15,192
Total amount of fees paid to insurance company	USD $1,529
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,192
Amount paid for insurance broker fees	1529
Additional information about fees paid to insurance broker	BROKER/CONSULTANT BONUS.
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	396
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $8,163
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,163
Insurance broker name	SEE ATTACHED

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

4250

Policy instance

Insurance contract or identification number	4250
Number of Individuals Covered	89
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $17,367
Total amount of fees paid to insurance company	USD $756
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $445,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,367
Amount paid for insurance broker fees	756
Additional information about fees paid to insurance broker	BROKER/CONSULTANT BONUS.
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7526601

Policy instance

Insurance contract or identification number	E7526601
Number of Individuals Covered	61
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $9,588
Total amount of fees paid to insurance company	USD $1,192
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,588
Amount paid for insurance broker fees	1192
Additional information about fees paid to insurance broker	BROKER/CONSULTANT BONUS.
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	823
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,738
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,738
Insurance broker name	SEE ATTACHED

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	747
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $3,747
Total amount of fees paid to insurance company	USD $182,757
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,420,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,747
Amount paid for insurance broker fees	182757
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	823
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
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 $23,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	823
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

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

Policy contract number

00423509

Policy instance

Insurance contract or identification number	00423509
Number of Individuals Covered	32
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $1,692
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,692
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	763
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7526601

Policy instance

Insurance contract or identification number	E7526601
Number of Individuals Covered	43
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $7,215
Total amount of fees paid to insurance company	USD $409
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,215
Amount paid for insurance broker fees	409
Insurance broker name	SEE ATTACHED

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

G4250

Policy instance

Insurance contract or identification number	G4250
Number of Individuals Covered	119
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $244
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	244
Insurance broker name	SEE ATTACHED

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	251
Insurance policy start date	2013-03-01
Insurance policy end date	2014-03-01
Total amount of commissions paid to insurance broker	USD $16,437
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,437
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	253
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $40,206
Total amount of fees paid to insurance company	USD $2,911
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $231,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,206
Amount paid for insurance broker fees	2911
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109

Policy instance

Insurance contract or identification number	E3367109
Number of Individuals Covered	56
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $8,869
Total amount of fees paid to insurance company	USD $616
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,869
Amount paid for insurance broker fees	616
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	294
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,786
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,786
Insurance broker name	SEE ATTACHED

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

4250

Policy instance

Insurance contract or identification number	4250
Number of Individuals Covered	77
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $14,891
Total amount of fees paid to insurance company	USD $756
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $372,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,891
Amount paid for insurance broker fees	756
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	763
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $2,221
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,221
Insurance broker name	SEE ATTACHED

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	644
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $3,039
Total amount of fees paid to insurance company	USD $147,447
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,569,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,039
Amount paid for insurance broker fees	147447
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	763
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	59
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,289
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,289
Insurance broker name	SEE ATTACHED

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	644
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $137,183
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,324,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137,183
Insurance broker name	SEE ATTACHED

AMERICAN VISION SOURCE (National Association of Insurance Commissioners NAIC id number: 707 )

Policy contract number

GROUP 034

Policy instance

Insurance contract or identification number	GROUP 034
Number of Individuals Covered	160
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,986
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,986
Insurance broker name	SEE ATTACHED

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

4250

Policy instance

Insurance contract or identification number	4250
Number of Individuals Covered	73
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $18,425
Total amount of fees paid to insurance company	USD $549
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $314,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,425
Amount paid for insurance broker fees	549
Insurance broker name	SEE ATTACHED

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

Policy contract number

00423509

Policy instance

Insurance contract or identification number	00423509
Number of Individuals Covered	33
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $1,738
Total amount of fees paid to insurance company	USD $198
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,738
Amount paid for insurance broker fees	198
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	210
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $3,195
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,195
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109

Policy instance

Insurance contract or identification number	E3367109
Number of Individuals Covered	61
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $9,174
Total amount of fees paid to insurance company	USD $972
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,174
Amount paid for insurance broker fees	972
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	227
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $31,042
Total amount of fees paid to insurance company	USD $3,132
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,042
Amount paid for insurance broker fees	3132
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7526601

Policy instance

Insurance contract or identification number	E7526601
Number of Individuals Covered	54
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $6,129
Total amount of fees paid to insurance company	USD $550
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,129
Amount paid for insurance broker fees	550
Insurance broker name	SEE ATTACHED

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

G4250

Policy instance

Insurance contract or identification number	G4250
Number of Individuals Covered	103
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $396
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	396
Insurance broker name	SEE ATTACHED

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	253
Insurance policy start date	2012-03-01
Insurance policy end date	2013-03-01
Total amount of commissions paid to insurance broker	USD $15,032
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,032
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	603
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $1,956
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,956
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	15
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $159
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $159
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	603
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	603
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	63
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $2,172
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,172
Amount paid for insurance broker fees	0
Insurance broker name	SEE ATTACHED

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	644
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $127,444
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,187,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127,444
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	587
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

AMERICAN VISION SOURCE (National Association of Insurance Commissioners NAIC id number: 707 )

Policy contract number

GROUP 034

Policy instance

Insurance contract or identification number	GROUP 034
Number of Individuals Covered	151
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $2,756
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,756
Insurance broker name	SEE ATTACHED

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

4250

Policy instance

Insurance contract or identification number	4250
Number of Individuals Covered	74
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $17,412
Total amount of fees paid to insurance company	USD $567
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $323,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,412
Amount paid for insurance broker fees	567
Insurance broker name	SEE ATTACHED

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

Policy contract number

00423509

Policy instance

Insurance contract or identification number	00423509
Number of Individuals Covered	27
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $1,655
Total amount of fees paid to insurance company	USD $183
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,655
Amount paid for insurance broker fees	183
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	200
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $3,248
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,248
Amount paid for insurance broker fees	0
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109

Policy instance

Insurance contract or identification number	E3367109
Number of Individuals Covered	62
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $10,626
Total amount of fees paid to insurance company	USD $2,097
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,626
Amount paid for insurance broker fees	2097
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	219
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $28,259
Total amount of fees paid to insurance company	USD $3,687
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,259
Amount paid for insurance broker fees	3687
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7526601

Policy instance

Insurance contract or identification number	E7526601
Number of Individuals Covered	51
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $5,572
Total amount of fees paid to insurance company	USD $738
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,572
Amount paid for insurance broker fees	738
Insurance broker name	SEE ATTACHED

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

G4250

Policy instance

Insurance contract or identification number	G4250
Number of Individuals Covered	112
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $50
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	50
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	587
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $1,782
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,782
Insurance broker name	SEE ATTACHED

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	587
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEE ATTACHED

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

Policy contract number

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	211
Insurance policy start date	2011-03-01
Insurance policy end date	2012-03-01
Total amount of commissions paid to insurance broker	USD $13,822
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,822
Insurance broker name	SEE ATTACHED

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	14
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $150
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $150
Amount paid for insurance broker fees	0
Insurance broker name	SEE ATTACHED

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7526601

Policy instance

Insurance contract or identification number	E7526601
Number of Individuals Covered	50
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $12,020
Total amount of fees paid to insurance company	USD $1,385
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $43,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

729280

Policy instance

Insurance contract or identification number	729280
Number of Individuals Covered	644
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $128,385
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,567,702
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

G000859H

Policy instance

Insurance contract or identification number	G000859H
Number of Individuals Covered	218
Insurance policy start date	2010-03-01
Insurance policy end date	2011-03-01
Total amount of commissions paid to insurance broker	USD $12,880
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

05471

Policy instance

Insurance contract or identification number	05471
Number of Individuals Covered	540
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $1,688
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN VISION SOURCE (National Association of Insurance Commissioners NAIC id number: 707 )

Policy contract number

GROUP 034

Policy instance

Insurance contract or identification number	GROUP 034
Number of Individuals Covered	141
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,613
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

004250

Policy instance

Insurance contract or identification number	004250
Number of Individuals Covered	82
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $19,488
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $339,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

G4250

Policy instance

Insurance contract or identification number	G4250
Number of Individuals Covered	99
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

95890000

Policy instance

Insurance contract or identification number	95890000
Number of Individuals Covered	200
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $5,379
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3367109

Policy instance

Insurance contract or identification number	E3367109
Number of Individuals Covered	61
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $11,929
Total amount of fees paid to insurance company	USD $1,113
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $54,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7057102

Policy instance

Insurance contract or identification number	E7057102
Number of Individuals Covered	226
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $53,266
Total amount of fees paid to insurance company	USD $6,181
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,968
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

00423509

Policy instance

Insurance contract or identification number	00423509
Number of Individuals Covered	22
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $1,396
Total amount of fees paid to insurance company	USD $265
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	GILLMAN SERVICES, INC.
Employer identification number (EIN):	741597662
NAIC Classification:	441110
NAIC Description:	New Car Dealers

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	2008-05-27
Company Identification Number:	0695232
Legal Registered Office Address:	11848 ROCK LANDING DR SUITE 102 SUITE 102 NEWPORT NEWS United States of America (USA) 23606