401k Plan data: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN plan

CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	CAPITAL HOTEL FLEXIBLE BENEFITS PLAN
Plan identification number	503

CAPITAL HOTEL FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

THE CAPITAL HOTEL JOINT VENTURE has sponsored the creation of one or more 401k plans.

Company Name: THE CAPITAL HOTEL JOINT VENTURE

Employer identification number (EIN): 752190406

NAIC Classification: 721110
NAIC Description: Hotels (except Casino Hotels) and Motels

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITAL HOTEL FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2021-01-01 ALLYSON THOMPSON 2022-08-09 ALLYSON THOMPSON 2022-08-09
503 2020-01-01
503 2019-01-01
503 2018-01-01
503 2017-01-01 MONICA STAGGERS MONICA STAGGERS 2018-07-31
503 2016-01-01 MONICA STAGGERS MONICA STAGGERS 2017-10-16
503 2015-01-01 MONICA STAGGERS MONICA STAGGERS 2016-10-12
503 2014-01-01 MONICA STAGGERS MONICA STAGGERS 2015-10-13
503 2013-01-01 MONICA STAGGERS MONICA STAGGERS 2014-10-14
503 2012-01-01 MONICA STAGGERS MONICA STAGGERS 2013-10-10
503 2011-01-01 MONICA STAGGERS MONICA STAGGERS 2012-10-08

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2021-01-01	ALLYSON THOMPSON	2022-08-09	ALLYSON THOMPSON	2022-08-09
503	2020-01-01
503	2019-01-01
503	2018-01-01
503	2017-01-01	MONICA STAGGERS		MONICA STAGGERS	2018-07-31
503	2016-01-01	MONICA STAGGERS		MONICA STAGGERS	2017-10-16
503	2015-01-01	MONICA STAGGERS		MONICA STAGGERS	2016-10-12
503	2014-01-01	MONICA STAGGERS		MONICA STAGGERS	2015-10-13
503	2013-01-01	MONICA STAGGERS		MONICA STAGGERS	2014-10-14
503	2012-01-01	MONICA STAGGERS		MONICA STAGGERS	2013-10-10
503	2011-01-01	MONICA STAGGERS		MONICA STAGGERS	2012-10-08

Plan Statistics for CAPITAL HOTEL FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for CAPITAL HOTEL FLEXIBLE BENEFITS PLAN

Measure Date Value
2020: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 76
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1
Number of retired or separated participants receiving benefits 2020-01-01 7
Total of all active and inactive participants 2020-01-01 8
2019: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 76
Number of other retired or separated participants entitled to future benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 77
2018: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 93
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 81
Total of all active and inactive participants 2018-01-01 81
2017: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 161
Total of all active and inactive participants 2017-01-01 161
2016: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 172
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 159
Total of all active and inactive participants 2016-01-01 159
2015: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 172
Total of all active and inactive participants 2015-01-01 172
2014: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 184
Total of all active and inactive participants 2014-01-01 184
2013: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 179
Total of all active and inactive participants 2013-01-01 179
2012: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 90
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 162
Number of retired or separated participants receiving benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 162
2011: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 90
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 90

Measure	Date	Value
2020: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	76
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1
Number of retired or separated participants receiving benefits	2020-01-01	7
Total of all active and inactive participants	2020-01-01	8
2019: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	76
Number of other retired or separated participants entitled to future benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	77
2018: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	93
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	81
Total of all active and inactive participants	2018-01-01	81
2017: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	161
Total of all active and inactive participants	2017-01-01	161
2016: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	172
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	159
Total of all active and inactive participants	2016-01-01	159
2015: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	172
Total of all active and inactive participants	2015-01-01	172
2014: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	184
Total of all active and inactive participants	2014-01-01	184
2013: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	179
Total of all active and inactive participants	2013-01-01	179
2012: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	90
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	162
Number of retired or separated participants receiving benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	162
2011: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	90
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	90

Form 5500 Responses for CAPITAL HOTEL FLEXIBLE BENEFITS PLAN

2020: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CAPITAL HOTEL FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

01F6541

Policy instance

Insurance contract or identification number	01F6541
Number of Individuals Covered	30
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,350
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $400,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,350
Insurance broker organization code?	3

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

Policy contract number

GUC0B37W

Policy instance

Insurance contract or identification number	GUC0B37W
Number of Individuals Covered	13
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $550
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $550
Insurance broker organization code?	3

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

Policy contract number

GLTD0B37W

Policy instance

Insurance contract or identification number	GLTD0B37W
Number of Individuals Covered	13
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $850
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $850
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

403006586 00000

Policy instance

Insurance contract or identification number	403006586 00000
Number of Individuals Covered	17
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $56
Total amount of fees paid to insurance company	USD $35
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $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 $51
Amount paid for insurance broker fees	35
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 22535

Policy instance

Insurance contract or identification number	400001000 22535
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $554
Total amount of fees paid to insurance company	USD $333
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $504
Amount paid for insurance broker fees	333
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10228043 00000

Policy instance

Insurance contract or identification number	10228043 00000
Number of Individuals Covered	11
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $825
Total amount of fees paid to insurance company	USD $384
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $773
Amount paid for insurance broker fees	384
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITED OF OMAHA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0B37W

Policy instance

Insurance contract or identification number	GUG0B37W
Number of Individuals Covered	13
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $846
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $846
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	48
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,658
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,658
Insurance broker organization code?	3

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

Policy contract number

GLTD0B37W

Policy instance

Insurance contract or identification number	GLTD0B37W
Number of Individuals Covered	32
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,178
Total amount of fees paid to insurance company	USD $250
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,178
Amount paid for insurance broker fees	250
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUC0B37W

Policy instance

Insurance contract or identification number	GUC0B37W
Number of Individuals Covered	31
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $943
Total amount of fees paid to insurance company	USD $273
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $943
Amount paid for insurance broker fees	273
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

UNITED OF OMAHA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0B37W

Policy instance

Insurance contract or identification number	GUG0B37W
Number of Individuals Covered	32
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,150
Total amount of fees paid to insurance company	USD $244
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,150
Amount paid for insurance broker fees	244
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

403006586 00000

Policy instance

Insurance contract or identification number	403006586 00000
Number of Individuals Covered	115
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $86
Total amount of fees paid to insurance company	USD $45
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 22535

Policy instance

Insurance contract or identification number	400001000 22535
Number of Individuals Covered	121
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $813
Total amount of fees paid to insurance company	USD $375
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $739
Amount paid for insurance broker fees	375
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10228043 00000

Policy instance

Insurance contract or identification number	10228043 00000
Number of Individuals Covered	71
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,363
Total amount of fees paid to insurance company	USD $411
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,278
Amount paid for insurance broker fees	411
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

136-41317200002

Policy instance

Insurance contract or identification number	136-41317200002
Number of Individuals Covered	105
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $130
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104
Insurance broker organization code?	3

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

Policy contract number

01F6541

Policy instance

Insurance contract or identification number	01F6541
Number of Individuals Covered	137
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $15,716
Total amount of fees paid to insurance company	USD $3,618
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $524,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,716
Amount paid for insurance broker fees	3618
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	145
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,142
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,142
Insurance broker organization code?	3

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

Policy contract number

136-41317200002

Policy instance

Insurance contract or identification number	136-41317200002
Number of Individuals Covered	125
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $148
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118
Insurance broker organization code?	3

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	150
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,975
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,975
Insurance broker organization code?	3

UNITED OF OMAHA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0B37W

Policy instance

Insurance contract or identification number	GUG0B37W
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,046
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,046
Insurance broker organization code?	3

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

Policy contract number

GUC0B37W

Policy instance

Insurance contract or identification number	GUC0B37W
Number of Individuals Covered	35
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,172
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,172
Insurance broker organization code?	3

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

Policy contract number

GLTD0B37W

Policy instance

Insurance contract or identification number	GLTD0B37W
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,073
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,073
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

403006586 00000

Policy instance

Insurance contract or identification number	403006586 00000
Number of Individuals Covered	121
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $111
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $101
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 22535

Policy instance

Insurance contract or identification number	400001000 22535
Number of Individuals Covered	125
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $917
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $834
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10228043 00000

Policy instance

Insurance contract or identification number	10228043 00000
Number of Individuals Covered	79
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,461
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,370
Insurance broker organization code?	3

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

776022

Policy instance

Insurance contract or identification number	776022
Number of Individuals Covered	144
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,517
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,517
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

403006586 00000

Policy instance

Insurance contract or identification number	403006586 00000
Number of Individuals Covered	111
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $99
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SVCS GRP LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 22535

Policy instance

Insurance contract or identification number	400001000 22535
Number of Individuals Covered	110
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $978
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,895
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
Insurance broker name	BENEFIT ADVISORS SVCS GRP LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10228043 00000

Policy instance

Insurance contract or identification number	10228043 00000
Number of Individuals Covered	81
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $1,688
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,583
Insurance broker organization code?	3
Insurance broker name	BENEFIT ADVISORS SVCS GRP LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	151
Insurance policy start date	2017-01-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $529
Total amount of fees paid to insurance company	USD $47
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $529
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	105
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $334
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $334
Insurance broker name	STEPHENS INSURANCE, LLC

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	161
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,671
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,671
Insurance broker name	STEPHENS INSURANCE, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,312
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,312
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	63
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $1,513
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,513
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	63
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $2,044
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,044
Insurance broker name	STEPHENS INSURANCE, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	101
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $392
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $392
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	156
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $3,344
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,344
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	169
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $5,153
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,153
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	172
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,388
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,388
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	162
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $3,330
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,330
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	111
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $370
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 $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 $370
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	66
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $2,569
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,569
Insurance broker name	STEPHENS INSURANCE, LLC

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	184
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,916
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,916
Insurance broker name	STEPHENS INSURANCE, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	185
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $5,526
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,526
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	38
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $1,483
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,483
Insurance broker name	STEPHENS INSURANCE, LLC

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	179
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,766
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,766
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	37
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,262
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,262
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	76
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,544
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,544
Insurance broker name	STEPHENS INSURANCE, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	1242
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,799
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 $77,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,799
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	161
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $3,272
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,272
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	177
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,446
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,446
Insurance broker organization code?	3
Insurance broker name	STEPHENS INSURANCE, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	157
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,437
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,437
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	25
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $869
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $869
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	62
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,070
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,070
Insurance broker name	STEPHENS INSURANCE, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	65
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $204
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 $4,144
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
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	112
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $2,837
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,837
Insurance broker name	STEPHENS INSURANCE, LLC

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	162
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,762
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,762
Insurance broker name	STEPHENS INSURANCE, LLC

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

Policy contract number

TM05574953 0003

Policy instance

Insurance contract or identification number	TM05574953 0003
Number of Individuals Covered	89
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $2,767
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30172-02

Policy instance

Insurance contract or identification number	30172-02
Number of Individuals Covered	55
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $143
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 $3,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	64
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $2,254
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

202693

Policy instance

Insurance contract or identification number	202693
Number of Individuals Covered	27
Insurance policy start date	2011-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $985
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 95442 )

Policy contract number

150062

Policy instance

Insurance contract or identification number	150062
Number of Individuals Covered	139
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,513
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

925

Policy instance

Insurance contract or identification number	925
Number of Individuals Covered	140
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,264
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	THE CAPITAL HOTEL JOINT VENTURE
Employer identification number (EIN):	752190406
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels