401k Plan data: FRED HAAS TOYOTA HEALTH CARE PLAN plan

FRED HAAS TOYOTA HEALTH CARE PLAN 401k Plan overview

Plan Name	FRED HAAS TOYOTA HEALTH CARE PLAN
Plan identification number	501

FRED HAAS TOYOTA HEALTH CARE PLAN Benefits

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

401k Sponsoring company profile

FRED HAAS MOTORS, LTD. has sponsored the creation of one or more 401k plans.

Company Name: FRED HAAS MOTORS, LTD.

Employer identification number (EIN): 741674758

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FRED HAAS TOYOTA HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 MISSY BARTELL 2023-10-16 MARK HAAS 2023-10-16
501 2021-01-01 MISSY BARTELL 2022-07-25 MARK HAAS 2022-08-01
501 2020-01-01 MISSY BARTELL 2021-10-05 MARK HAAS 2021-10-05
501 2019-01-01 MISSY BARTELL 2020-07-30 MARK HAAS 2020-07-30
501 2018-01-01 MISSY BARTELL 2019-08-15 MARK HAAS 2019-08-15
501 2017-01-01
501 2016-04-01
501 2015-04-01
501 2014-04-01
501 2013-04-01
501 2012-04-01 MARK HAAS
501 2011-04-01 W. CLINTON BENNETT
501 2009-04-01 W. CLINTON BENNETT, CPA W. CLINTON BENNET, CPA 2011-01-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	MISSY BARTELL	2023-10-16	MARK HAAS	2023-10-16
501	2021-01-01	MISSY BARTELL	2022-07-25	MARK HAAS	2022-08-01
501	2020-01-01	MISSY BARTELL	2021-10-05	MARK HAAS	2021-10-05
501	2019-01-01	MISSY BARTELL	2020-07-30	MARK HAAS	2020-07-30
501	2018-01-01	MISSY BARTELL	2019-08-15	MARK HAAS	2019-08-15
501	2017-01-01
501	2016-04-01
501	2015-04-01
501	2014-04-01
501	2013-04-01
501	2012-04-01	MARK HAAS
501	2011-04-01	W. CLINTON BENNETT
501	2009-04-01	W. CLINTON BENNETT, CPA		W. CLINTON BENNET, CPA	2011-01-13

Plan Statistics for FRED HAAS TOYOTA HEALTH CARE PLAN

401k plan membership statisitcs for FRED HAAS TOYOTA HEALTH CARE PLAN

Measure Date Value
2022: FRED HAAS TOYOTA HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 643
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 649
Number of retired or separated participants receiving benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 649
2021: FRED HAAS TOYOTA HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 685
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 643
Number of retired or separated participants receiving benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 643
2020: FRED HAAS TOYOTA HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 686
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 685
Number of retired or separated participants receiving benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 685
2019: FRED HAAS TOYOTA HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 738
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 686
Number of retired or separated participants receiving benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 686
2018: FRED HAAS TOYOTA HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 751
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 738
Number of retired or separated participants receiving benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 738
2017: FRED HAAS TOYOTA HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 766
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 751
Number of retired or separated participants receiving benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 751
2016: FRED HAAS TOYOTA HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-04-01 856
Total number of active participants reported on line 7a of the Form 5500 2016-04-01 766
Number of retired or separated participants receiving benefits 2016-04-01 0
Total of all active and inactive participants 2016-04-01 766
2015: FRED HAAS TOYOTA HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 367
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 856
Number of retired or separated participants receiving benefits 2015-04-01 0
Total of all active and inactive participants 2015-04-01 856
2014: FRED HAAS TOYOTA HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 352
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 367
Number of retired or separated participants receiving benefits 2014-04-01 0
Total of all active and inactive participants 2014-04-01 367
2013: FRED HAAS TOYOTA HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 365
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 352
Number of retired or separated participants receiving benefits 2013-04-01 4
Total of all active and inactive participants 2013-04-01 356
2012: FRED HAAS TOYOTA HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 302
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 355
Number of retired or separated participants receiving benefits 2012-04-01 10
Total of all active and inactive participants 2012-04-01 365
2011: FRED HAAS TOYOTA HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-04-01 314
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 302
Total of all active and inactive participants 2011-04-01 302
2009: FRED HAAS TOYOTA HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-04-01 272
Total number of active participants reported on line 7a of the Form 5500 2009-04-01 294
Number of other retired or separated participants entitled to future benefits 2009-04-01 8
Total of all active and inactive participants 2009-04-01 302

Measure	Date	Value
2022: FRED HAAS TOYOTA HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	643
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	649
Number of retired or separated participants receiving benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	649
2021: FRED HAAS TOYOTA HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	685
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	643
Number of retired or separated participants receiving benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	643
2020: FRED HAAS TOYOTA HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	686
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	685
Number of retired or separated participants receiving benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	685
2019: FRED HAAS TOYOTA HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	738
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	686
Number of retired or separated participants receiving benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	686
2018: FRED HAAS TOYOTA HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	751
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	738
Number of retired or separated participants receiving benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	738
2017: FRED HAAS TOYOTA HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	766
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	751
Number of retired or separated participants receiving benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	751
2016: FRED HAAS TOYOTA HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	856
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	766
Number of retired or separated participants receiving benefits	2016-04-01	0
Total of all active and inactive participants	2016-04-01	766
2015: FRED HAAS TOYOTA HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	367
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	856
Number of retired or separated participants receiving benefits	2015-04-01	0
Total of all active and inactive participants	2015-04-01	856
2014: FRED HAAS TOYOTA HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	352
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	367
Number of retired or separated participants receiving benefits	2014-04-01	0
Total of all active and inactive participants	2014-04-01	367
2013: FRED HAAS TOYOTA HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	365
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	352
Number of retired or separated participants receiving benefits	2013-04-01	4
Total of all active and inactive participants	2013-04-01	356
2012: FRED HAAS TOYOTA HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	302
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	355
Number of retired or separated participants receiving benefits	2012-04-01	10
Total of all active and inactive participants	2012-04-01	365
2011: FRED HAAS TOYOTA HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	314
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	302
Total of all active and inactive participants	2011-04-01	302
2009: FRED HAAS TOYOTA HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-04-01	272
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	294
Number of other retired or separated participants entitled to future benefits	2009-04-01	8
Total of all active and inactive participants	2009-04-01	302

Form 5500 Responses for FRED HAAS TOYOTA HEALTH CARE PLAN

2022: FRED HAAS TOYOTA HEALTH CARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Mulitple employer plan
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: FRED HAAS TOYOTA HEALTH CARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Mulitple employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FRED HAAS TOYOTA HEALTH CARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Mulitple employer plan
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: FRED HAAS TOYOTA HEALTH CARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Mulitple employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FRED HAAS TOYOTA HEALTH CARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Mulitple employer plan
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: FRED HAAS TOYOTA HEALTH CARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Mulitple employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: FRED HAAS TOYOTA HEALTH CARE PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Mulitple employer plan
2016-04-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: FRED HAAS TOYOTA HEALTH CARE PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Mulitple employer plan
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: FRED HAAS TOYOTA HEALTH CARE PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Mulitple employer plan
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: FRED HAAS TOYOTA HEALTH CARE PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Mulitple employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: FRED HAAS TOYOTA HEALTH CARE PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Mulitple employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: FRED HAAS TOYOTA HEALTH CARE PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Mulitple employer plan
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2009: FRED HAAS TOYOTA HEALTH CARE PLAN 2009 form 5500 responses
2009-04-01	Type of plan entity	Mulitple employer plan
2009-04-01	This submission is the final filing	No
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	22
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,489
Total amount of fees paid to insurance company	USD $7
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $21,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $600
Insurance broker organization code?	3
Amount paid for insurance broker fees	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	135
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,153
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,153
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	38
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,523
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,523
Insurance broker organization code?	3

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,511
Total amount of fees paid to insurance company	USD $109
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $15,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $536
Insurance broker organization code?	3
Amount paid for insurance broker fees	80

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $75
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	56
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,648
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,648
Insurance broker organization code?	3

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

Policy contract number

VF026170

Policy instance

Insurance contract or identification number	VF026170
Number of Individuals Covered	623
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $23,626
Total amount of fees paid to insurance company	USD $8,115
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $157,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,626
Amount paid for insurance broker fees	8115

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

Policy contract number

154373

Policy instance

Insurance contract or identification number	154373
Number of Individuals Covered	413
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,978
Total amount of fees paid to insurance company	USD $5,010
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,978
Amount paid for insurance broker fees	5010
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	27
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,896
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,896
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	123
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,212
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,212
Insurance broker organization code?	3

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	10
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,641
Total amount of fees paid to insurance company	USD $481
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $17,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,272
Amount paid for insurance broker fees	99
Insurance broker organization code?	3

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	23
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,721
Total amount of fees paid to insurance company	USD $59
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $20,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $669
Amount paid for insurance broker fees	10
Insurance broker organization code?	3

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $77
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	47
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,585
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,585
Insurance broker organization code?	3

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

Policy contract number

VF026170

Policy instance

Insurance contract or identification number	VF026170
Number of Individuals Covered	593
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $24,175
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $161,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,175
Insurance broker organization code?	3

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

Policy contract number

154373

Policy instance

Insurance contract or identification number	154373
Number of Individuals Covered	389
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,617
Total amount of fees paid to insurance company	USD $5,100
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,617
Amount paid for insurance broker fees	5100
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	137
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,226
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,226
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	25
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,536
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,536
Insurance broker organization code?	3

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	9
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,166
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $16,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $509
Insurance broker organization code?	3

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,533
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $23,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $639
Insurance broker organization code?	3

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $85
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,040
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
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,564
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,564
Insurance broker organization code?	3

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

Policy contract number

700454

Policy instance

Insurance contract or identification number	700454
Number of Individuals Covered	107
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $9,851
Total amount of fees paid to insurance company	USD $821
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $61,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,851
Amount paid for insurance broker fees	821
Insurance broker organization code?	3

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

Policy contract number

700453

Policy instance

Insurance contract or identification number	700453
Number of Individuals Covered	495
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $9,597
Total amount of fees paid to insurance company	USD $800
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $58,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,597
Amount paid for insurance broker fees	800
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	135
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,236
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,236
Insurance broker organization code?	3

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $77
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	23
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,829
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,829
Insurance broker organization code?	3

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	13
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,219
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $19,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $519
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	57
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,533
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,533
Insurance broker organization code?	3

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

Policy contract number

700453

Policy instance

Insurance contract or identification number	700453
Number of Individuals Covered	545
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $8,222
Total amount of fees paid to insurance company	USD $685
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $54,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,222
Amount paid for insurance broker fees	685
Insurance broker organization code?	3

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

Policy contract number

700454

Policy instance

Insurance contract or identification number	700454
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $9,584
Total amount of fees paid to insurance company	USD $799
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $63,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,584
Amount paid for insurance broker fees	799
Insurance broker organization code?	3

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	25
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,712
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $26,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $700
Insurance broker organization code?	3

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

Policy contract number

700454

Policy instance

Insurance contract or identification number	700454
Number of Individuals Covered	74
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $10,148
Total amount of fees paid to insurance company	USD $846
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $67,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,148
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	846
Insurance broker name	GALLAGHER BENEFIT SVCS INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5344,CP5344

Policy instance

Insurance contract or identification number	CD5344,CP5344
Number of Individuals Covered	0
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $341
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $4,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $341
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	55
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $906
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $906
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $77
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3
Insurance broker name	SA GENERAL AGENCY INC

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	31
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,471
Total amount of fees paid to insurance company	USD $103
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $32,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $995
Amount paid for insurance broker fees	39
Insurance broker organization code?	3
Insurance broker name	STEVEN VERMETTE INC

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,736
Total amount of fees paid to insurance company	USD $138
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $19,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $684
Amount paid for insurance broker fees	52
Insurance broker organization code?	3
Insurance broker name	JOHN ROE

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	0
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $568
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $5,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $445
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	0
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $983
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $4,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $841
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	16
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,085
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,085
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

785032

Policy instance

Insurance contract or identification number	785032
Number of Individuals Covered	119
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $2,100
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,100
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

700453

Policy instance

Insurance contract or identification number	700453
Number of Individuals Covered	309
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $7,860
Total amount of fees paid to insurance company	USD $655
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $52,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,860
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	655
Insurance broker name	GALLAGHER BENEFIT SVCS INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS932

Policy instance

Insurance contract or identification number	VS932
Number of Individuals Covered	1
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $5
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47
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
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

E4003596

Policy instance

Insurance contract or identification number	E4003596
Number of Individuals Covered	5
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $218
Total amount of fees paid to insurance company	USD $11
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83
Amount paid for insurance broker fees	4
Insurance broker organization code?	3
Insurance broker name	NANCY LAPHAM

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

Policy contract number

E3995339

Policy instance

Insurance contract or identification number	E3995339
Number of Individuals Covered	11
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $517
Total amount of fees paid to insurance company	USD $48
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $204
Amount paid for insurance broker fees	19
Insurance broker organization code?	3
Insurance broker name	MICHAEL A CHANDLER

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $79
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3
Insurance broker name	DALLAS C MORENO

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS8394

Policy instance

Insurance contract or identification number	VS8394
Number of Individuals Covered	12
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

40330

Policy instance

Insurance contract or identification number	40330
Number of Individuals Covered	5
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5344,CP5344

Policy instance

Insurance contract or identification number	CD5344,CP5344
Number of Individuals Covered	10
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $583
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $5,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $583
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	47
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,742
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $17,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,402
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	31
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $3,537
Total amount of fees paid to insurance company	USD $369
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $33,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,339
Amount paid for insurance broker fees	176
Insurance broker organization code?	3
Insurance broker name	SHEALY BENEFIT SERVICES INC

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	14
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $1,326
Total amount of fees paid to insurance company	USD $30
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $19,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $575
Amount paid for insurance broker fees	12
Insurance broker organization code?	3
Insurance broker name	ROBERT J HUMPHREY

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

403516 0010

Policy instance

Insurance contract or identification number	403516 0010
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AGGREGATE/SPECIFIC STOP LOSS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	62
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $710
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $544
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	25
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $319
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $279
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	16
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $110
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	9
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $133
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $1,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $122
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	658
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,251
Total amount of fees paid to insurance company	USD $2,588
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $141,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,251
Amount paid for insurance broker fees	2588
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	23
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,083
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $11,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $821
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	13
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $67
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 $877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	613
Insurance policy start date	2014-03-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,268
Total amount of fees paid to insurance company	USD $3,156
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
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $122,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,268
Amount paid for insurance broker fees	3156
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	10
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $153
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $1,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $136
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	42
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,141
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
Other welfare benefits provided	PREPAID
Welfare Benefit Premiums Paid to Carrier	USD $11,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $753
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD5344, CP5344

Policy instance

Insurance contract or identification number	CD5344, CP5344
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $46
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 $470
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
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	48
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $454
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 $6,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $290
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	19
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $785
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 $7,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $463
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	15
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $2,732
Total amount of fees paid to insurance company	USD $462
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $20,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,009
Amount paid for insurance broker fees	89
Insurance broker name	ROBERT J HUMPHREY

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

Policy contract number

E3995339

Policy instance

Insurance contract or identification number	E3995339
Number of Individuals Covered	11
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $1,587
Total amount of fees paid to insurance company	USD $354
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $9,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $536
Amount paid for insurance broker fees	58
Insurance broker organization code?	3
Insurance broker name	BRYAN JAMES INGLIS

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	32
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $3,388
Total amount of fees paid to insurance company	USD $342
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $33,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,186
Amount paid for insurance broker fees	57
Insurance broker organization code?	3
Insurance broker name	SHEALY BENEFIT SERVICES INC

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

Policy contract number

E4003596

Policy instance

Insurance contract or identification number	E4003596
Number of Individuals Covered	5
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $876
Total amount of fees paid to insurance company	USD $214
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $5,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $276
Amount paid for insurance broker fees	34
Insurance broker organization code?	3
Insurance broker name	NANCY LAPHAM

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	1
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $161
Total amount of fees paid to insurance company	USD $21
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47
Amount paid for insurance broker fees	3
Insurance broker organization code?	3
Insurance broker name	MICHAEL A CHANDLER

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS932

Policy instance

Insurance contract or identification number	VS932
Number of Individuals Covered	1
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $8
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 $82
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
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	25
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $170
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS8394

Policy instance

Insurance contract or identification number	VS8394
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $19
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 $208
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
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

40330

Policy instance

Insurance contract or identification number	40330
Number of Individuals Covered	4
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $51
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	19
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $1,688
Total amount of fees paid to insurance company	USD $201
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $20,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $706
Amount paid for insurance broker fees	53
Insurance broker organization code?	3
Insurance broker name	ROBERT J HUMPHREY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	6
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $12
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 $412
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
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	26
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $662
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
Other welfare benefits provided	PREPAID
Welfare Benefit Premiums Paid to Carrier	USD $7,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $342
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	3
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $71
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $721
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
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

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

Policy contract number

819959-SHORT

Policy instance

Insurance contract or identification number	819959-SHORT
Number of Individuals Covered	156
Insurance policy start date	2013-03-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $242
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 $19,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	242
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	10
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $52
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	593
Insurance policy start date	2013-03-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,994
Total amount of fees paid to insurance company	USD $1,748
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
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $105,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,994
Amount paid for insurance broker fees	1748
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	11
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $550
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $5,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $333
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

E3995685

Policy instance

Insurance contract or identification number	E3995685
Number of Individuals Covered	2
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $675
Total amount of fees paid to insurance company	USD $220
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $183
Amount paid for insurance broker fees	14
Insurance broker organization code?	3
Insurance broker name	MICHAEL A CHANDLER

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

Policy contract number

E3995339

Policy instance

Insurance contract or identification number	E3995339
Number of Individuals Covered	8
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $697
Total amount of fees paid to insurance company	USD $102
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $7,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $308
Amount paid for insurance broker fees	23
Insurance broker organization code?	3
Insurance broker name	MICHAEL A CHANDLER

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

Policy contract number

E4003596

Policy instance

Insurance contract or identification number	E4003596
Number of Individuals Covered	4
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $320
Total amount of fees paid to insurance company	USD $40
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126
Amount paid for insurance broker fees	10
Insurance broker organization code?	3
Insurance broker name	NANCY LAPHAM

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

403516 0010

Policy instance

Insurance contract or identification number	403516 0010
Number of Individuals Covered	359
Insurance policy start date	2013-03-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $58,968
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
Other welfare benefits provided	AGGREGATE/SPECIFIC STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $393,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,968
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	29
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $149
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 $3,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $139
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	37
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $5,385
Total amount of fees paid to insurance company	USD $1,269
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $32,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,856
Amount paid for insurance broker fees	140
Insurance broker organization code?	3
Insurance broker name	STEVEN VERMETTE INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	1
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $11
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 $90
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	16
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $622
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
Other welfare benefits provided	PREPAID
Welfare Benefit Premiums Paid to Carrier	USD $4,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Insurance broker organization code?	3
Insurance broker name	JIM C. HARRIS & COMPANY, LLP

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	1
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $21
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $166
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
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

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

Policy contract number

819959

Policy instance

Insurance contract or identification number	819959
Number of Individuals Covered	174
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	584
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $10,120
Total amount of fees paid to insurance company	USD $1,614
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
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $109,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,120
Amount paid for insurance broker fees	1614
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

E3995339

Policy instance

Insurance contract or identification number	E3995339
Number of Individuals Covered	8
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $2,400
Total amount of fees paid to insurance company	USD $514
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $860
Amount paid for insurance broker fees	157
Insurance broker organization code?	3
Insurance broker name	BRUCE D AKERS

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

403516 0010

Policy instance

Insurance contract or identification number	403516 0010
Number of Individuals Covered	348
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $61,531
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AGGREGATE/SPECIFIC STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $410,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,531
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

E7526916

Policy instance

Insurance contract or identification number	E7526916
Number of Individuals Covered	48
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $1,018
Total amount of fees paid to insurance company	USD $102
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $11,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $371
Amount paid for insurance broker fees	53
Insurance broker organization code?	3
Insurance broker name	JOHN ROE

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

Policy contract number

E3995677

Policy instance

Insurance contract or identification number	E3995677
Number of Individuals Covered	21
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $7,255
Total amount of fees paid to insurance company	USD $1,137
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $24,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,552
Amount paid for insurance broker fees	467
Insurance broker organization code?	3
Insurance broker name	DAVID A DICKEY

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

Policy contract number

E3995925

Policy instance

Insurance contract or identification number	E3995925
Number of Individuals Covered	37
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $8,596
Total amount of fees paid to insurance company	USD $2,746
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $28,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,006
Amount paid for insurance broker fees	550
Insurance broker organization code?	3
Insurance broker name	STEVEN VERMETTE INC

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

Policy contract number

E4003596

Policy instance

Insurance contract or identification number	E4003596
Number of Individuals Covered	6
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $999
Total amount of fees paid to insurance company	USD $171
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313
Amount paid for insurance broker fees	57
Insurance broker organization code?	3
Insurance broker name	NANCY LAPHAM

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	3
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $89
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 $670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	5
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $430
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $3,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $430
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	12
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $187
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $187
Insurance broker organization code?	3
Insurance broker name	KELLY SCOTT AND COMPANY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	10
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	5
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	1
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	15
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $330
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
Other welfare benefits provided	PREPAID
Welfare Benefit Premiums Paid to Carrier	USD $4,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	1
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $41
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $473
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

E7526916

Policy instance

Insurance contract or identification number	E7526916
Number of Individuals Covered	48
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $2,507
Total amount of fees paid to insurance company	USD $590
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $34,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

403516 0010

Policy instance

Insurance contract or identification number	403516 0010
Number of Individuals Covered	306
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $53,431
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AGGREGATE/SPECIFIC STOP LOSS
Welfare Benefit Premiums Paid to Carrier	USD $356,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	7
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $303
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $4,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

819959

Policy instance

Insurance contract or identification number	819959
Number of Individuals Covered	164
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	511
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $10,156
Total amount of fees paid to insurance company	USD $14,238
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
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $103,169
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

E7526916

Policy instance

Insurance contract or identification number	E7526916
Number of Individuals Covered	53
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $2,526
Total amount of fees paid to insurance company	USD $127
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $37,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS818

Policy instance

Insurance contract or identification number	VS818
Number of Individuals Covered	6
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS817

Policy instance

Insurance contract or identification number	VS817
Number of Individuals Covered	10
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS819

Policy instance

Insurance contract or identification number	VS819
Number of Individuals Covered	3
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

30329,20329

Policy instance

Insurance contract or identification number	30329,20329
Number of Individuals Covered	15
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $551
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
Other welfare benefits provided	PREPAID
Welfare Benefit Premiums Paid to Carrier	USD $5,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

20330

Policy instance

Insurance contract or identification number	20330
Number of Individuals Covered	3
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $90
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

819959

Policy instance

Insurance contract or identification number	819959
Number of Individuals Covered	139
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

677151G

Policy instance

Insurance contract or identification number	677151G
Number of Individuals Covered	493
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $9,891
Total amount of fees paid to insurance company	USD $497
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
Other welfare benefits provided	ACCIDENT, DISABILITY & HEALTH
Welfare Benefit Premiums Paid to Carrier	USD $104,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

50329,40329

Policy instance

Insurance contract or identification number	50329,40329
Number of Individuals Covered	8
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $408
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
Other welfare benefits provided	PREPAID PLAN
Welfare Benefit Premiums Paid to Carrier	USD $4,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

EXRK

Policy instance

Insurance contract or identification number	EXRK
Number of Individuals Covered	280
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $49,548
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 $330,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

FRED HAAS INTERESTS 401(K) PLAN [EIN = 760530327]

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Company Name:	FRED HAAS MOTORS, LTD.
Employer identification number (EIN):	741674758
NAIC Classification:	441110
NAIC Description:	New Car Dealers