401k Plan data: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN plan

WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 401k Plan overview

Plan Name	WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN
Plan identification number	501

WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN Benefits

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

401k Sponsoring company profile

WEST WICHITA FAMILY PHYSICIANS, PA has sponsored the creation of one or more 401k plans.

Company Name: WEST WICHITA FAMILY PHYSICIANS, PA

Employer identification number (EIN): 742848808

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01 D. SCOTT KARDATZKE D. SCOTT KARDATZKE 2019-01-25
501 2016-07-01 D. SCOTT KARDATZKE WILLIAM C. LOEWEN 2018-03-22
501 2015-07-01 WILLIAM C. LOEWEN WILLIAM C. LOEWEN
501 2015-07-01 WILLIAM C. LOEWEN WILLIAM C. LOEWEN 2017-01-13
501 2014-07-01 WILLIAM C. LOEWEN WILLIAM C. LOEWEN 2016-05-05
501 2014-07-01 WILLIAM C. LOEWEN WILLIAM C. LOEWEN
501 2013-07-01 WILLIAM C. LOEWEN
501 2012-07-01 WILLIAM C. LOEWEN
501 2011-07-01 WILLIAM C. LOEWEN
501 2010-01-01 WILLIAM C. LOEWEN
501 2009-01-01 WILLIAM C. LOEWEN

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01
501	2020-07-01
501	2019-07-01
501	2018-07-01
501	2017-07-01	D. SCOTT KARDATZKE	D. SCOTT KARDATZKE	2019-01-25
501	2016-07-01	D. SCOTT KARDATZKE	WILLIAM C. LOEWEN	2018-03-22
501	2015-07-01	WILLIAM C. LOEWEN	WILLIAM C. LOEWEN
501	2015-07-01	WILLIAM C. LOEWEN	WILLIAM C. LOEWEN	2017-01-13
501	2014-07-01	WILLIAM C. LOEWEN	WILLIAM C. LOEWEN	2016-05-05
501	2014-07-01	WILLIAM C. LOEWEN	WILLIAM C. LOEWEN
501	2013-07-01	WILLIAM C. LOEWEN
501	2012-07-01	WILLIAM C. LOEWEN
501	2011-07-01	WILLIAM C. LOEWEN
501	2010-01-01	WILLIAM C. LOEWEN
501	2009-01-01	WILLIAM C. LOEWEN

Plan Statistics for WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN

401k plan membership statisitcs for WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN

Measure Date Value
2021: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 199
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 195
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 195
2020: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 234
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 199
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 199
2019: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 229
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 234
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 234
2018: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 226
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 229
Number of retired or separated participants receiving benefits 2018-07-01 0
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 229
2017: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 233
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 226
Number of retired or separated participants receiving benefits 2017-07-01 0
Number of other retired or separated participants entitled to future benefits 2017-07-01 0
Total of all active and inactive participants 2017-07-01 226
2016: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 234
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 233
Number of retired or separated participants receiving benefits 2016-07-01 0
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 233
2015: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 232
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 234
Number of retired or separated participants receiving benefits 2015-07-01 0
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 234
2014: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 229
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 232
Number of retired or separated participants receiving benefits 2014-07-01 0
Number of other retired or separated participants entitled to future benefits 2014-07-01 0
Total of all active and inactive participants 2014-07-01 232
2013: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 218
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 229
Total of all active and inactive participants 2013-07-01 229
2012: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 210
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 218
Total of all active and inactive participants 2012-07-01 218
2011: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 208
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 210
Total of all active and inactive participants 2011-07-01 210
2010: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 204
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 208
Total of all active and inactive participants 2010-01-01 208
2009: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 204
Total of all active and inactive participants 2009-01-01 204

Measure	Date	Value
2021: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	199
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	195
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	195
2020: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	234
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	199
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	199
2019: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	229
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	234
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	234
2018: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	226
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	229
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	229
2017: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	233
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	226
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	226
2016: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	234
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	233
Number of retired or separated participants receiving benefits	2016-07-01	0
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	233
2015: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	232
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	234
Number of retired or separated participants receiving benefits	2015-07-01	0
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	234
2014: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	229
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	232
Number of retired or separated participants receiving benefits	2014-07-01	0
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	232
2013: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	218
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	229
Total of all active and inactive participants	2013-07-01	229
2012: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	210
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	218
Total of all active and inactive participants	2012-07-01	218
2011: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	208
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	210
Total of all active and inactive participants	2011-07-01	210
2010: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	204
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	208
Total of all active and inactive participants	2010-01-01	208
2009: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	204
Total of all active and inactive participants	2009-01-01	204

Form 5500 Responses for WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN

2021: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	Yes
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	Yes
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: WEST WICHITA FAMILY PHYSICIANS, PA CAFETERIA PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

LTZ17

Policy instance

Insurance contract or identification number	LTZ17
Number of Individuals Covered	22
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,553
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $15,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $889
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	142
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $9,287
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,287
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	367
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $39,379
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,636,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,379
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPS 327123

Policy instance

Insurance contract or identification number	VPS 327123
Number of Individuals Covered	29
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,270
Total amount of fees paid to insurance company	USD $415
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,270
Amount paid for insurance broker fees	415
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAI 825736

Policy instance

Insurance contract or identification number	VAI 825736
Number of Individuals Covered	20
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,069
Total amount of fees paid to insurance company	USD $113
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,069
Amount paid for insurance broker fees	113
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

8843265

Policy instance

Insurance contract or identification number	8843265
Number of Individuals Covered	24
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,718
Total amount of fees paid to insurance company	USD $898
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,511
Insurance broker organization code?	3
Amount paid for insurance broker fees	898

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VCI 800686

Policy instance

Insurance contract or identification number	VCI 800686
Number of Individuals Covered	45
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,180
Total amount of fees paid to insurance company	USD $126
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $5,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,180
Amount paid for insurance broker fees	126
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 156182

Policy instance

Insurance contract or identification number	GL 156182
Number of Individuals Covered	195
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,288
Total amount of fees paid to insurance company	USD $1,665
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $52,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,288
Amount paid for insurance broker fees	1665
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207057

Policy instance

Insurance contract or identification number	VAR 207057
Number of Individuals Covered	190
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $560
Total amount of fees paid to insurance company	USD $116
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $560
Amount paid for insurance broker fees	116
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 127749

Policy instance

Insurance contract or identification number	LTD 127749
Number of Individuals Covered	195
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,560
Total amount of fees paid to insurance company	USD $1,709
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,560
Amount paid for insurance broker fees	1709
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	149
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $10,287
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,287
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	383
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $42,944
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,731,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,944
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPS 327123

Policy instance

Insurance contract or identification number	VPS 327123
Number of Individuals Covered	35
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $3,255
Total amount of fees paid to insurance company	USD $541
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,255
Amount paid for insurance broker fees	541
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAI 825736

Policy instance

Insurance contract or identification number	VAI 825736
Number of Individuals Covered	24
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,183
Total amount of fees paid to insurance company	USD $152
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,183
Amount paid for insurance broker fees	152
Insurance broker organization code?	3

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

Policy contract number

LTZ17

Policy instance

Insurance contract or identification number	LTZ17
Number of Individuals Covered	26
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,866
Total amount of fees paid to insurance company	USD $71
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $18,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,070
Amount paid for insurance broker fees	51
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VCI 800686

Policy instance

Insurance contract or identification number	VCI 800686
Number of Individuals Covered	53
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,201
Total amount of fees paid to insurance company	USD $153
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,201
Amount paid for insurance broker fees	153
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 156182

Policy instance

Insurance contract or identification number	GL 156182
Number of Individuals Covered	195
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $5,334
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $53,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,334
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207057

Policy instance

Insurance contract or identification number	VAR 207057
Number of Individuals Covered	199
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $574
Total amount of fees paid to insurance company	USD $136
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $574
Amount paid for insurance broker fees	136
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 127749

Policy instance

Insurance contract or identification number	LTD 127749
Number of Individuals Covered	194
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,552
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,552
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

8843265

Policy instance

Insurance contract or identification number	8843265
Number of Individuals Covered	25
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $20,678
Total amount of fees paid to insurance company	USD $241
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,158
Insurance broker organization code?	3
Amount paid for insurance broker fees	241

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAI 825736

Policy instance

Insurance contract or identification number	VAI 825736
Number of Individuals Covered	33
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,533
Total amount of fees paid to insurance company	USD $160
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,664
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
Amount paid for insurance broker fees	160
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPS 327123

Policy instance

Insurance contract or identification number	VPS 327123
Number of Individuals Covered	44
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $4,204
Total amount of fees paid to insurance company	USD $711
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,204
Amount paid for insurance broker fees	711
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	399
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $50,113
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,905,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,113
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	171
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $11,950
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,950
Insurance broker organization code?	3

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

Policy contract number

LTZ17

Policy instance

Insurance contract or identification number	LTZ17
Number of Individuals Covered	38
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $3,546
Total amount of fees paid to insurance company	USD $789
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $23,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,216
Amount paid for insurance broker fees	563
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VCI 800686

Policy instance

Insurance contract or identification number	VCI 800686
Number of Individuals Covered	62
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,609
Total amount of fees paid to insurance company	USD $194
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,609
Amount paid for insurance broker fees	194
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 156182

Policy instance

Insurance contract or identification number	GL 156182
Number of Individuals Covered	233
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $5,818
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,818
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 127749

Policy instance

Insurance contract or identification number	LTD 127749
Number of Individuals Covered	233
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $4,599
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,599
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

8843265

Policy instance

Insurance contract or identification number	8843265
Number of Individuals Covered	25
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $11,411
Total amount of fees paid to insurance company	USD $249
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,341
Amount paid for insurance broker fees	28
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207057

Policy instance

Insurance contract or identification number	VAR 207057
Number of Individuals Covered	234
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $642
Total amount of fees paid to insurance company	USD $144
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $642
Amount paid for insurance broker fees	144
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAI 825736

Policy instance

Insurance contract or identification number	VAI 825736
Number of Individuals Covered	26
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,233
Total amount of fees paid to insurance company	USD $138
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $6,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,233
Amount paid for insurance broker fees	138
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPS 327123

Policy instance

Insurance contract or identification number	VPS 327123
Number of Individuals Covered	40
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $4,644
Total amount of fees paid to insurance company	USD $571
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,644
Amount paid for insurance broker fees	571
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	408
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $47,578
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,681,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,578
Insurance broker organization code?	3

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	185
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,544
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,544
Insurance broker organization code?	3

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

Policy contract number

LTZ17

Policy instance

Insurance contract or identification number	LTZ17
Number of Individuals Covered	36
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $8,403
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $14,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,881
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VCI 800686

Policy instance

Insurance contract or identification number	VCI 800686
Number of Individuals Covered	64
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,695
Total amount of fees paid to insurance company	USD $170
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,695
Amount paid for insurance broker fees	170
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 156182

Policy instance

Insurance contract or identification number	GL 156182
Number of Individuals Covered	229
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $5,787
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,787
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207057

Policy instance

Insurance contract or identification number	VAR 207057
Number of Individuals Covered	240
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $635
Total amount of fees paid to insurance company	USD $140
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $635
Amount paid for insurance broker fees	140
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 127749

Policy instance

Insurance contract or identification number	LTD 127749
Number of Individuals Covered	229
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $4,586
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,586
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

8843265

Policy instance

Insurance contract or identification number	8843265
Number of Individuals Covered	24
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $52,151
Total amount of fees paid to insurance company	USD $64,911
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,151
Amount paid for insurance broker fees	27003
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VCI 800686

Policy instance

Insurance contract or identification number	VCI 800686
Number of Individuals Covered	67
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,303
Total amount of fees paid to insurance company	USD $95
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 156182

Policy instance

Insurance contract or identification number	GL 156182
Number of Individuals Covered	227
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $4,988
Total amount of fees paid to insurance company	USD $588
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207057

Policy instance

Insurance contract or identification number	VAR 207057
Number of Individuals Covered	226
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $539
Total amount of fees paid to insurance company	USD $66
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 127749

Policy instance

Insurance contract or identification number	LTD 127749
Number of Individuals Covered	226
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,859
Total amount of fees paid to insurance company	USD $852
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	1
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $11
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	36
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,956
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $16,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAI 825736

Policy instance

Insurance contract or identification number	VAI 825736
Number of Individuals Covered	27
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,201
Total amount of fees paid to insurance company	USD $94
Other welfare benefits provided	VOLUNTARY ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $6,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPS 327123

Policy instance

Insurance contract or identification number	VPS 327123
Number of Individuals Covered	40
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,185
Total amount of fees paid to insurance company	USD $353
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09613

Policy instance

Insurance contract or identification number	09613
Number of Individuals Covered	407
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $48,049
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,603,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	189
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $11,009
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	234
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $4,713
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,963
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )

Policy contract number

3403070000

Policy instance

Insurance contract or identification number	3403070000
Number of Individuals Covered	403
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,359,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	68
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $5,877
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $557
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	174
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $2,903
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,903
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000064100128

Policy instance

Insurance contract or identification number	000064100128
Number of Individuals Covered	204
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $341
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
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	GALLAGHER BENEFIT SERVICES, INC.

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	234
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $4,012
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,926
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000064100128

Policy instance

Insurance contract or identification number	000064100128
Number of Individuals Covered	204
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $341
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
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	GALLAGHER BENEFIT SERVICES, INC.

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	232
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,961
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,961
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	71
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $5,919
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $842
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	232
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Life Insurance Welfare Benefit	Yes
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

COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )

Policy contract number

3403070000

Policy instance

Insurance contract or identification number	3403070000
Number of Individuals Covered	432
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,260,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	175
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $2,259
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,259
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	78
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $7,804
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,007
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000064100128

Policy instance

Insurance contract or identification number	000064100128
Number of Individuals Covered	204
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $341
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
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	HERITAGE ONE, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	170
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,235
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,235
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	229
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,594
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $855
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )

Policy contract number

3403070000

Policy instance

Insurance contract or identification number	3403070000
Number of Individuals Covered	396
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,180,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	229
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $4,431
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,834
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	218
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,517
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,674
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	218
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,299
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,711
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	417
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,333,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	79
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $7,046
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $981
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000064100128

Policy instance

Insurance contract or identification number	000064100128
Number of Individuals Covered	204
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $341
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
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	HERITAGE ONE, INC.

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	174
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,982
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,982
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00002

Policy instance

Insurance contract or identification number	23402-000-00002
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	210
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,644
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	210
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,656
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	411
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,425,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

64100128

Policy instance

Insurance contract or identification number	64100128
Number of Individuals Covered	204
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $341
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	ACCIDENTAL DEATH & DISMEMBERMEMT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	173
Insurance policy start date	2011-07-30
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $5,190
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 $109,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	77
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $9,038
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	208
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,152
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	171
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,315
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 $106,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	408
Insurance policy start date	2011-01-01
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $747,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

23402-000-00001

Policy instance

Insurance contract or identification number	23402-000-00001
Number of Individuals Covered	168
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,331
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )

Policy contract number

09252

Policy instance

Insurance contract or identification number	09252
Number of Individuals Covered	427
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,490,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	208
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,200
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	208
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,451
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

2340200000002

Policy instance

Insurance contract or identification number	2340200000002
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72452

Policy instance

Insurance contract or identification number	72452
Number of Individuals Covered	67
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,890
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

630953

Policy instance

Insurance contract or identification number	630953
Number of Individuals Covered	208
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $2,341
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

64100128

Policy instance

Insurance contract or identification number	64100128
Number of Individuals Covered	204
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $171
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	ACCIDENTAL DEATH & DISMEMBERMEMT
Welfare Benefit Premiums Paid to Carrier	USD $1,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

64100128

Policy instance

Insurance contract or identification number	64100128
Number of Individuals Covered	204
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $341
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	ACCIDENTAL DEATH & DISMEMBERMEMT
Welfare Benefit Premiums Paid to Carrier	USD $2,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	WEST WICHITA FAMILY PHYSICIANS, PA
Employer identification number (EIN):	742848808
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)