401k Plan data: AFFINITY APPAREL WELFARE BENEFITS PLAN plan

AFFINITY APPAREL WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	AFFINITY APPAREL WELFARE BENEFITS PLAN
Plan identification number	501

AFFINITY APPAREL WELFARE 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

AFFINITY SPECIALTY APPAREL, INC has sponsored the creation of one or more 401k plans.

Company Name: AFFINITY SPECIALTY APPAREL, INC

Employer identification number (EIN): 800967836

NAIC Classification: 424300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AFFINITY APPAREL WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01
501 2018-01-01 BRITTANIE STACY BRITTANIE STACY 2019-07-01
501 2017-01-01 BILL TUCKER BILL TUCKER 2018-07-18
501 2016-01-01 BILL TUCKER
501 2015-01-01 BILL TUCKER
501 2014-01-01 BRITTANIE STACY

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2019-01-01
501	2018-01-01	BRITTANIE STACY	BRITTANIE STACY	2019-07-01
501	2017-01-01	BILL TUCKER	BILL TUCKER	2018-07-18
501	2016-01-01	BILL TUCKER
501	2015-01-01	BILL TUCKER
501	2014-01-01	BRITTANIE STACY

Plan Statistics for AFFINITY APPAREL WELFARE BENEFITS PLAN

401k plan membership statisitcs for AFFINITY APPAREL WELFARE BENEFITS PLAN

Measure Date Value
2019: AFFINITY APPAREL WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 98
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 62
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 62
2018: AFFINITY APPAREL WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 235
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 96
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 98
2017: AFFINITY APPAREL WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 289
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 140
Number of retired or separated participants receiving benefits 2017-01-01 95
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 235
2016: AFFINITY APPAREL WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 374
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 190
Number of retired or separated participants receiving benefits 2016-01-01 99
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 289
2015: AFFINITY APPAREL WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 509
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 265
Number of retired or separated participants receiving benefits 2015-01-01 109
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 374
2014: AFFINITY APPAREL WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 370
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 370
Number of retired or separated participants receiving benefits 2014-01-01 139
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 509

Measure	Date	Value
2019: AFFINITY APPAREL WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	98
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	62
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	62
2018: AFFINITY APPAREL WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	235
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	96
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	98
2017: AFFINITY APPAREL WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	289
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	140
Number of retired or separated participants receiving benefits	2017-01-01	95
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	235
2016: AFFINITY APPAREL WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	374
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	190
Number of retired or separated participants receiving benefits	2016-01-01	99
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	289
2015: AFFINITY APPAREL WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	509
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	265
Number of retired or separated participants receiving benefits	2015-01-01	109
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	374
2014: AFFINITY APPAREL WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	370
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	370
Number of retired or separated participants receiving benefits	2014-01-01	139
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	509

Form 5500 Responses for AFFINITY APPAREL WELFARE BENEFITS PLAN

2019: AFFINITY APPAREL WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: AFFINITY APPAREL WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: AFFINITY APPAREL WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: AFFINITY APPAREL WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: AFFINITY APPAREL WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: AFFINITY APPAREL WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	62
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	7
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $919
Total amount of fees paid to insurance company	USD $525
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $919
Insurance broker organization code?	3
Amount paid for insurance broker fees	487
Additional information about fees paid to insurance broker	BROKER BONUS

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

W41276

Policy instance

Insurance contract or identification number	W41276
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 $21,184
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $632,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,184
Insurance broker organization code?	3

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172749

Policy instance

Insurance contract or identification number	00172749
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,480
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,480
Insurance broker organization code?	3

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

Policy contract number

0902064

Policy instance

Insurance contract or identification number	0902064
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

488

Policy instance

Insurance contract or identification number	488
Number of Individuals Covered	129
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,975
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,975
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

BKRC88434

Policy instance

Insurance contract or identification number	BKRC88434
Number of Individuals Covered	17
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,542
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,542
Insurance broker organization code?	3

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	7
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $71
Total amount of fees paid to insurance company	USD $70
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71
Insurance broker organization code?	3
Amount paid for insurance broker fees	65
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	130
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,087
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,087
Insurance broker organization code?	3

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	110
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $1,915
Total amount of fees paid to insurance company	USD $653
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $38,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,915
Insurance broker organization code?	3
Amount paid for insurance broker fees	534
Additional information about fees paid to insurance broker	BROKER BONUS

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

007413700

Policy instance

Insurance contract or identification number	007413700
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $98
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $98
Insurance broker organization code?	3

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

488

Policy instance

Insurance contract or identification number	488
Number of Individuals Covered	143
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,128
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,128
Insurance broker organization code?	3

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

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	138
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,456
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,456
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	96
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	7
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $863
Total amount of fees paid to insurance company	USD $259
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $863
Insurance broker organization code?	3
Amount paid for insurance broker fees	229
Additional information about fees paid to insurance broker	BROKER BONUS

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172749

Policy instance

Insurance contract or identification number	00172749
Number of Individuals Covered	132
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $30,336
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $885,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,784
Insurance broker organization code?	3

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

Policy contract number

0902064

Policy instance

Insurance contract or identification number	0902064
Number of Individuals Covered	62
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA7258

Policy instance

Insurance contract or identification number	GA7258
Number of Individuals Covered	140
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
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 $3,500
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,500
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC.

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

Policy contract number

0902064

Policy instance

Insurance contract or identification number	0902064
Number of Individuals Covered	82
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

007413700

Policy instance

Insurance contract or identification number	007413700
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $237
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $237
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST, INC.

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172749

Policy instance

Insurance contract or identification number	00172749
Number of Individuals Covered	173
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $47,328
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,166,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,328
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST INC.

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

488

Policy instance

Insurance contract or identification number	488
Number of Individuals Covered	198
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,162
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,162
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST, INC.

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	147
Insurance policy start date	2016-06-01
Insurance policy end date	2017-05-31
Total amount of commissions paid to insurance broker	USD $1,660
Total amount of fees paid to insurance company	USD $109
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $36,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,660
Insurance broker organization code?	3
Amount paid for insurance broker fees	109
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker name	AON RISK SERVICES CENTRAL INC.

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	10
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $997
Total amount of fees paid to insurance company	USD $41
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $997
Insurance broker organization code?	3
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker name	AON RISK SERVICES CENTRAL

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00012228

Policy instance

Insurance contract or identification number	ER00012228
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $113
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $113
Insurance broker organization code?	3
Insurance broker name	MCGRIFF, SEIBELS & WILLIAMS OF GA

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00012228

Policy instance

Insurance contract or identification number	ER00012228
Number of Individuals Covered	24
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,597
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,597
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MCGRIFF SEIBELS & WILLIAMS OF GA

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	39
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $3,255
Total amount of fees paid to insurance company	USD $45
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,549
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker name	AON RISK SERVICES CENTRAL INC.

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172749

Policy instance

Insurance contract or identification number	00172749
Number of Individuals Covered	259
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $47,104
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,114,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,104
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVCIES NORTHEST INC

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

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	290
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,497
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,497
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

C7424

Policy instance

Insurance contract or identification number	C7424
Insurance policy start date	2015-01-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $436
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $436
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SOLUTIONS

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

488

Policy instance

Insurance contract or identification number	488
Number of Individuals Covered	280
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,461
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,461
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

007413700

Policy instance

Insurance contract or identification number	007413700
Number of Individuals Covered	22
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $928
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $928
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST

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

Policy contract number

00477624

Policy instance

Insurance contract or identification number	00477624
Number of Individuals Covered	34
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,028
Total amount of fees paid to insurance company	USD $2,492
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,897
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES
Insurance broker name	BB&T INSURANCE SERVICES I

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA7258

Policy instance

Insurance contract or identification number	GA7258
Number of Individuals Covered	41
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $231,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0902064

Policy instance

Insurance contract or identification number	0902064
Number of Individuals Covered	119
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	195
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,458
Total amount of fees paid to insurance company	USD $47
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $76,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,848
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker name	AON RISK SERVICES CENTRAL INC.

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	567
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $5,652
Total amount of fees paid to insurance company	USD $2,801
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $104,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,652
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	BB&T INS SERVICES INC

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

C7424

Policy instance

Insurance contract or identification number	C7424
Number of Individuals Covered	14
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,573
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $66,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,210
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SOLUTIONS

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

Policy contract number

207430G

Policy instance

Insurance contract or identification number	207430G
Number of Individuals Covered	76
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $7,370
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $57,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,732
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BB&T INS SERVICES INC

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

GA7258

Policy instance

Insurance contract or identification number	GA7258
Number of Individuals Covered	65
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $129,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0902064

Policy instance

Insurance contract or identification number	0902064
Number of Individuals Covered	94
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172749

Policy instance

Insurance contract or identification number	00172749
Number of Individuals Covered	239
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $39,552
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $766,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,288
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK INSURANCE AGENCY

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00012228

Policy instance

Insurance contract or identification number	ER00012228
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,627
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $36,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,627
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MCGRIFF SEIBELS & WILLIAMS OF GA

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

488

Policy instance

Insurance contract or identification number	488
Number of Individuals Covered	243
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,046
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,046
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AON RISK SERVICES NORTHEAST, INC.

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA7258

Policy instance

Insurance contract or identification number	GA7258
Number of Individuals Covered	52
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $171,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

68388-4

Policy instance

Insurance contract or identification number	68388-4
Number of Individuals Covered	257
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,787
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	1787
Additional information about fees paid to insurance broker	WRITING AGENT
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC

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

Policy contract number

00477624

Policy instance

Insurance contract or identification number	00477624
Number of Individuals Covered	84
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,230
Total amount of fees paid to insurance company	USD $1,587
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $41,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,230
Amount paid for insurance broker fees	1587
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	MCGRIFF SEIBELS & WILLIAMS

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

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	307
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	AFFINITY SPECIALTY APPAREL, INC
Employer identification number (EIN):	800967836
NAIC Classification:	424300