FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN
Plan identification number	501

FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN Benefits

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

401k Sponsoring company profile

FIRST INTERSTATE BANCSYSTEM INC has sponsored the creation of one or more 401k plans.

Company Name:	FIRST INTERSTATE BANCSYSTEM INC
Employer identification number (EIN):	810331430
NAIC Classification:	522110
NAIC Description:	Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	RACHEL TURITTO	2023-07-21
501	2021-01-01	RACHEL TURITTO	2022-07-25
501	2020-01-01	RACHEL TURITTO	2021-07-06
501	2019-01-01	RACHEL TURITTO	2020-10-16
501	2018-01-01	RACHEL TURITTO	2019-10-14
501	2017-01-01
501	2016-01-01	MIKE CHERWIN
501	2015-01-01	STEVE MAASCH
501	2014-01-01	STEVE MAASCH
501	2013-01-01	STEVE MAASCH
501	2012-01-01	RAMONA DOLL
501	2011-01-01	RAMONA DOLL
501	2010-01-01	RAMONA DOLL
501	2009-01-01	RAMONA DOLL

Plan Statistics for FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN

401k plan membership statisitcs for FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN

Measure	Date	Value
2022: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,257
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	3,149
Number of retired or separated participants receiving benefits	2022-01-01	84
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	3,233
2021: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,257
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,999
Number of retired or separated participants receiving benefits	2021-01-01	62
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	2,061
2020: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,214
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,239
Number of retired or separated participants receiving benefits	2020-01-01	18
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	2,257
2019: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,153
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,154
Number of retired or separated participants receiving benefits	2019-01-01	60
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	2,214
2018: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,875
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,153
Number of retired or separated participants receiving benefits	2018-01-01	171
Number of other retired or separated participants entitled to future benefits	2018-01-01	25
Total of all active and inactive participants	2018-01-01	2,349
2017: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,547
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,362
Number of retired or separated participants receiving benefits	2017-01-01	159
Total of all active and inactive participants	2017-01-01	2,521
2016: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,261
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,442
Number of retired or separated participants receiving benefits	2016-01-01	125
Total of all active and inactive participants	2016-01-01	1,567
2015: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,441
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,451
Number of retired or separated participants receiving benefits	2015-01-01	101
Total of all active and inactive participants	2015-01-01	1,552
2014: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,334
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,319
Number of retired or separated participants receiving benefits	2014-01-01	93
Total of all active and inactive participants	2014-01-01	1,412
2013: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,459
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,397
Number of retired or separated participants receiving benefits	2013-01-01	82
Total of all active and inactive participants	2013-01-01	1,479
2012: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,387
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,383
Number of retired or separated participants receiving benefits	2012-01-01	66
Total of all active and inactive participants	2012-01-01	1,449
2011: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,501
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,344
Number of retired or separated participants receiving benefits	2011-01-01	62
Total of all active and inactive participants	2011-01-01	1,406
2010: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	1,546
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,484
Number of retired or separated participants receiving benefits	2010-01-01	59
Total of all active and inactive participants	2010-01-01	1,543
2009: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,538
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,480
Number of retired or separated participants receiving benefits	2009-01-01	49
Total of all active and inactive participants	2009-01-01	1,529

Financial Data on FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN

Measure	Date	Value
2019 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$1,710,000
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$1,710,000
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$3,576,600
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$3,576,600
Total income from all sources (including contributions)	2019-12-31	$18,726,465
Total income from all sources (including contributions)	2019-12-31	$18,726,465
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$20,877,789
Total of all expenses incurred	2019-12-31	$20,877,789
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$19,439,080
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$19,439,080
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$18,720,971
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$18,720,971
Value of total assets at end of year	2019-12-31	$0
Value of total assets at end of year	2019-12-31	$0
Value of total assets at beginning of year	2019-12-31	$4,017,924
Value of total assets at beginning of year	2019-12-31	$4,017,924
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$1,438,709
Total interest from all sources	2019-12-31	$0
Total interest from all sources	2019-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$654
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$654
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$654
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$654
Administrative expenses professional fees incurred	2019-12-31	$290,000
Administrative expenses professional fees incurred	2019-12-31	$290,000
Was this plan covered by a fidelity bond	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$7,292,133
Contributions received from participants	2019-12-31	$7,292,133
Participant contributions at beginning of year	2019-12-31	$498,518
Participant contributions at beginning of year	2019-12-31	$498,518
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$742,222
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$976,679
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$976,679
Administrative expenses (other) incurred	2019-12-31	$168,060
Administrative expenses (other) incurred	2019-12-31	$168,060
Liabilities. Value of operating payables at beginning of year	2019-12-31	$167,973
Liabilities. Value of operating payables at beginning of year	2019-12-31	$167,973
Total non interest bearing cash at beginning of year	2019-12-31	$119,657
Total non interest bearing cash at beginning of year	2019-12-31	$119,657
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$-2,151,324
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$-1,710,000
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$-1,710,000
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$441,324
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$441,324
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$327,771
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$327,771
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$327,771
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$327,771
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$900,249
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$900,249
Expenses. Payments to insurance carriers foe the provision of benefits	2019-12-31	$1,372,432
Expenses. Payments to insurance carriers foe the provision of benefits	2019-12-31	$1,372,432
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$4,840
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	Yes
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$10,686,616
Contributions received in cash from employer	2019-12-31	$10,686,616
Employer contributions (assets) at beginning of year	2019-12-31	$1,076,503
Employer contributions (assets) at beginning of year	2019-12-31	$1,076,503
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$18,066,648
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$18,066,648
Contract administrator fees	2019-12-31	$980,649
Contract administrator fees	2019-12-31	$980,649
Assets. Corporate common stocks other than exployer securities at beginning of year	2019-12-31	$118,547
Assets. Corporate common stocks other than exployer securities at beginning of year	2019-12-31	$118,547
Liabilities. Value of benefit claims payable at end of year	2019-12-31	$1,710,000
Liabilities. Value of benefit claims payable at end of year	2019-12-31	$1,710,000
Liabilities. Value of benefit claims payable at beginning of year	2019-12-31	$3,408,627
Liabilities. Value of benefit claims payable at beginning of year	2019-12-31	$3,408,627
Did the plan have assets held for investment	2019-12-31	No
Did the plan have assets held for investment	2019-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	No
Opinion of an independent qualified public accountant for this plan	2019-12-31	Unqualified
Accountancy firm name	2019-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2019-12-31	450250958
Accountancy firm EIN	2019-12-31	450250958
2018 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$3,576,600
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$2,288,863
Total income from all sources (including contributions)	2018-12-31	$21,354,162
Total loss/gain on sale of assets	2018-12-31	$31,006
Total of all expenses incurred	2018-12-31	$24,913,165
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$23,445,753
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$21,458,010
Value of total assets at end of year	2018-12-31	$4,017,924
Value of total assets at beginning of year	2018-12-31	$6,289,190
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$1,467,412
Total interest from all sources	2018-12-31	$38,983
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$60,603
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2018-12-31	$52,072
Administrative expenses professional fees incurred	2018-12-31	$242,233
Was this plan covered by a fidelity bond	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$6,515,012
Participant contributions at end of year	2018-12-31	$498,518
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$879,474
Value of other receiveables (less allowance for doubtful accounts) at end of year	2018-12-31	$976,679
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-12-31	$402,340
Administrative expenses (other) incurred	2018-12-31	$266,127
Liabilities. Value of operating payables at end of year	2018-12-31	$167,973
Liabilities. Value of operating payables at beginning of year	2018-12-31	$23,863
Total non interest bearing cash at end of year	2018-12-31	$119,657
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-3,559,003
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$441,324
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$4,000,327
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2018-12-31	$327,771
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2018-12-31	$3,327,286
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2018-12-31	$3,327,286
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2018-12-31	$38,983
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$900,249
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$2,058,028
Expenses. Payments to insurance carriers foe the provision of benefits	2018-12-31	$1,334,359
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-234,440
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$14,063,524
Employer contributions (assets) at end of year	2018-12-31	$1,076,503
Income. Dividends from common stock	2018-12-31	$8,531
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$22,111,394
Contract administrator fees	2018-12-31	$959,052
Assets. Corporate common stocks other than exployer securities at end of year	2018-12-31	$118,547
Assets. Corporate common stocks other than exployer securities at beginning of year	2018-12-31	$501,536
Liabilities. Value of benefit claims payable at end of year	2018-12-31	$3,408,627
Liabilities. Value of benefit claims payable at beginning of year	2018-12-31	$2,265,000
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Aggregate proceeds on sale of assets	2018-12-31	$416,296
Aggregate carrying amount (costs) on sale of assets	2018-12-31	$385,290
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2018-12-31	450250958
2017 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2017 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$2,288,863
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$1,474,155
Total income from all sources (including contributions)	2017-12-31	$18,980,159
Total loss/gain on sale of assets	2017-12-31	$8,749
Total of all expenses incurred	2017-12-31	$19,313,614
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$18,057,997
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$18,695,854
Value of total assets at end of year	2017-12-31	$6,289,190
Value of total assets at beginning of year	2017-12-31	$5,807,937
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$1,255,617
Total interest from all sources	2017-12-31	$19,899
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$67,068
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2017-12-31	$56,027
Administrative expenses professional fees incurred	2017-12-31	$342,671
Was this plan covered by a fidelity bond	2017-12-31	No
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$5,813,211
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$892,847
Value of other receiveables (less allowance for doubtful accounts) at end of year	2017-12-31	$402,340
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2017-12-31	$686,368
Administrative expenses (other) incurred	2017-12-31	$372,858
Liabilities. Value of operating payables at end of year	2017-12-31	$23,863
Liabilities. Value of operating payables at beginning of year	2017-12-31	$74,155
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$-333,455
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$4,000,327
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$4,333,782
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$2,058,028
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$1,884,146
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2017-12-31	$3,327,286
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2017-12-31	$2,854,964
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2017-12-31	$2,854,964
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2017-12-31	$19,899
Expenses. Payments to insurance carriers foe the provision of benefits	2017-12-31	$930,485
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$188,589
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$11,989,796
Income. Dividends from common stock	2017-12-31	$11,041
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$17,127,512
Contract administrator fees	2017-12-31	$540,088
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2017-12-31	No
Assets. Corporate common stocks other than exployer securities at end of year	2017-12-31	$501,536
Assets. Corporate common stocks other than exployer securities at beginning of year	2017-12-31	$382,459
Liabilities. Value of benefit claims payable at end of year	2017-12-31	$2,265,000
Liabilities. Value of benefit claims payable at beginning of year	2017-12-31	$1,400,000
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Aggregate proceeds on sale of assets	2017-12-31	$150,805
Aggregate carrying amount (costs) on sale of assets	2017-12-31	$142,056
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2017-12-31	450250958
2016 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2016 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$1,474,155
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$1,891,631
Total income from all sources (including contributions)	2016-12-31	$18,604,681
Total loss/gain on sale of assets	2016-12-31	$2,841
Total of all expenses incurred	2016-12-31	$17,364,032
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$16,069,839
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$18,454,020
Value of total assets at end of year	2016-12-31	$5,807,937
Value of total assets at beginning of year	2016-12-31	$4,984,764
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$1,294,193
Total interest from all sources	2016-12-31	$3,470
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$67,882
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2016-12-31	$59,870
Administrative expenses professional fees incurred	2016-12-31	$285,022
Was this plan covered by a fidelity bond	2016-12-31	No
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$5,867,459
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$765,316
Value of other receiveables (less allowance for doubtful accounts) at end of year	2016-12-31	$686,368
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2016-12-31	$1,412,972
Administrative expenses (other) incurred	2016-12-31	$474,892
Liabilities. Value of operating payables at end of year	2016-12-31	$74,155
Liabilities. Value of operating payables at beginning of year	2016-12-31	$111,631
Total non interest bearing cash at end of year	2016-12-31	$0
Total non interest bearing cash at beginning of year	2016-12-31	$639,006
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$1,240,649
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$4,333,782
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$3,093,133
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$1,884,146
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$1,749,235
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2016-12-31	$2,854,964
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2016-12-31	$829,424
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2016-12-31	$829,424
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-12-31	$3,470
Expenses. Payments to insurance carriers foe the provision of benefits	2016-12-31	$672,790
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$76,468
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$11,821,245
Income. Dividends from common stock	2016-12-31	$8,012
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$15,397,049
Contract administrator fees	2016-12-31	$534,279
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2016-12-31	No
Assets. Corporate common stocks other than exployer securities at end of year	2016-12-31	$382,459
Assets. Corporate common stocks other than exployer securities at beginning of year	2016-12-31	$354,127
Liabilities. Value of benefit claims payable at end of year	2016-12-31	$1,400,000
Liabilities. Value of benefit claims payable at beginning of year	2016-12-31	$1,780,000
Did the plan have assets held for investment	2016-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Aggregate proceeds on sale of assets	2016-12-31	$60,189
Aggregate carrying amount (costs) on sale of assets	2016-12-31	$57,348
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2016-12-31	450250958
2015 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2015 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$1,891,631
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$1,725,193
Total income from all sources (including contributions)	2015-12-31	$17,621,775
Total loss/gain on sale of assets	2015-12-31	$9,399
Total of all expenses incurred	2015-12-31	$19,836,818
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$18,463,116
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$17,652,869
Value of total assets at end of year	2015-12-31	$4,984,764
Value of total assets at beginning of year	2015-12-31	$7,033,369
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$1,373,702
Total interest from all sources	2015-12-31	$1,306
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$96,741
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2015-12-31	$85,237
Administrative expenses professional fees incurred	2015-12-31	$131,150
Was this plan covered by a fidelity bond	2015-12-31	No
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$5,807,433
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$633,596
Value of other receiveables (less allowance for doubtful accounts) at end of year	2015-12-31	$1,412,972
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2015-12-31	$129,632
Administrative expenses (other) incurred	2015-12-31	$544,718
Liabilities. Value of operating payables at end of year	2015-12-31	$111,631
Liabilities. Value of operating payables at beginning of year	2015-12-31	$145,193
Total non interest bearing cash at end of year	2015-12-31	$639,006
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-2,215,043
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$3,093,133
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$5,308,176
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$1,749,235
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$2,946,386
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-12-31	$829,424
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2015-12-31	$3,208,965
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2015-12-31	$3,208,965
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2015-12-31	$1,306
Expenses. Payments to insurance carriers foe the provision of benefits	2015-12-31	$708,844
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-138,540
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$11,211,840
Income. Dividends from common stock	2015-12-31	$11,504
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$17,754,272
Contract administrator fees	2015-12-31	$697,834
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2015-12-31	No
Assets. Corporate common stocks other than exployer securities at end of year	2015-12-31	$354,127
Assets. Corporate common stocks other than exployer securities at beginning of year	2015-12-31	$748,386
Liabilities. Value of benefit claims payable at end of year	2015-12-31	$1,780,000
Liabilities. Value of benefit claims payable at beginning of year	2015-12-31	$1,580,000
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Aggregate proceeds on sale of assets	2015-12-31	$447,506
Aggregate carrying amount (costs) on sale of assets	2015-12-31	$438,107
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2015-12-31	450250958
2014 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2014 401k financial data
Unrealized appreciation/depreciation of real estate assets	2014-12-31	$35,132
Total unrealized appreciation/depreciation of assets	2014-12-31	$35,132
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$1,725,193
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$1,313,264
Total income from all sources (including contributions)	2014-12-31	$16,305,085
Total loss/gain on sale of assets	2014-12-31	$154
Total of all expenses incurred	2014-12-31	$15,483,435
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$14,286,186
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$16,236,382
Value of total assets at end of year	2014-12-31	$7,033,369
Value of total assets at beginning of year	2014-12-31	$5,799,790
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$1,197,249
Total interest from all sources	2014-12-31	$1,053
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$82,120
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2014-12-31	$82,120
Administrative expenses professional fees incurred	2014-12-31	$1,011,309
Was this plan covered by a fidelity bond	2014-12-31	No
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$5,402,354
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$496,516
Value of other receiveables (less allowance for doubtful accounts) at end of year	2014-12-31	$129,632
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-12-31	$404,195
Administrative expenses (other) incurred	2014-12-31	$137,340
Liabilities. Value of operating payables at end of year	2014-12-31	$145,193
Liabilities. Value of operating payables at beginning of year	2014-12-31	$8,264
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$821,650
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$5,308,176
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$4,486,526
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$2,946,386
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$1,561,941
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-12-31	$3,208,965
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-12-31	$3,833,654
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-12-31	$3,833,654
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-12-31	$1,053
Expenses. Payments to insurance carriers foe the provision of benefits	2014-12-31	$754,018
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$-49,756
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$10,337,512
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$13,532,168
Contract administrator fees	2014-12-31	$48,600
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2014-12-31	No
Assets. Corporate common stocks other than exployer securities at end of year	2014-12-31	$748,386
Liabilities. Value of benefit claims payable at end of year	2014-12-31	$1,580,000
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$1,305,000
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Aggregate proceeds on sale of assets	2014-12-31	$23,699
Aggregate carrying amount (costs) on sale of assets	2014-12-31	$23,545
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2014-12-31	450250958
2013 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2013 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$1,313,264
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$1,648,164
Total income from all sources (including contributions)	2013-12-31	$17,124,209
Total of all expenses incurred	2013-12-31	$14,967,732
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$13,959,153
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$16,970,902
Value of total assets at end of year	2013-12-31	$5,799,790
Value of total assets at beginning of year	2013-12-31	$3,978,213
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,008,579
Total interest from all sources	2013-12-31	$1,350
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$52,647
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2013-12-31	$52,647
Administrative expenses professional fees incurred	2013-12-31	$955,528
Was this plan covered by a fidelity bond	2013-12-31	No
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$5,682,192
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$516,194
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-12-31	$404,195
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-12-31	$141,717
Liabilities. Value of operating payables at end of year	2013-12-31	$8,264
Liabilities. Value of operating payables at beginning of year	2013-12-31	$14,164
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$2,156,477
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$4,486,526
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$2,330,049
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$1,561,941
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$1,487,534
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-12-31	$3,833,654
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-12-31	$2,348,962
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-12-31	$2,348,962
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-12-31	$1,350
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$476,108
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$99,310
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$10,772,516
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$13,483,045
Contract administrator fees	2013-12-31	$53,051
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2013-12-31	No
Liabilities. Value of benefit claims payable at end of year	2013-12-31	$1,305,000
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$1,634,000
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2013-12-31	450250958
2012 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2012 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2012-12-31	$109,488
Total unrealized appreciation/depreciation of assets	2012-12-31	$109,488
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$1,648,164
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$1,281,952
Total income from all sources (including contributions)	2012-12-31	$16,803,473
Total of all expenses incurred	2012-12-31	$14,883,592
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$14,021,334
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$16,641,965
Value of total assets at end of year	2012-12-31	$3,978,213
Value of total assets at beginning of year	2012-12-31	$1,692,120
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$862,258
Total interest from all sources	2012-12-31	$3,262
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$48,758
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2012-12-31	$48,758
Administrative expenses professional fees incurred	2012-12-31	$792,615
Was this plan covered by a fidelity bond	2012-12-31	No
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$5,030,482
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$498,743
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2012-12-31	$109,050
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$141,717
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$102,623
Liabilities. Value of operating payables at end of year	2012-12-31	$14,164
Liabilities. Value of operating payables at beginning of year	2012-12-31	$9,952
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$1,919,881
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$2,330,049
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$410,168
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$1,487,534
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$1,233,150
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$2,348,962
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$305,900
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$305,900
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$3,262
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$514,575
Asset value of US Government securities at end of year	2012-12-31	$0
Asset value of US Government securities at beginning of year	2012-12-31	$50,447
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$11,112,740
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$13,397,709
Contract administrator fees	2012-12-31	$69,643
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2012-12-31	No
Liabilities. Value of benefit claims payable at end of year	2012-12-31	$1,634,000
Liabilities. Value of benefit claims payable at beginning of year	2012-12-31	$1,272,000
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2012-12-31	450250958
2011 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2011 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2011-12-31	$-2,225
Total unrealized appreciation/depreciation of assets	2011-12-31	$-2,225
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$1,281,952
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$1,977,143
Total income from all sources (including contributions)	2011-12-31	$16,052,403
Total of all expenses incurred	2011-12-31	$15,384,143
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$14,529,586
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$16,008,691
Value of total assets at end of year	2011-12-31	$1,692,120
Value of total assets at beginning of year	2011-12-31	$1,719,051
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$854,557
Total interest from all sources	2011-12-31	$4,245
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$44,375
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2011-12-31	$44,375
Administrative expenses professional fees incurred	2011-12-31	$773,479
Was this plan covered by a fidelity bond	2011-12-31	No
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$4,566,758
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$619,402
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-12-31	$102,623
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$125,671
Liabilities. Value of operating payables at end of year	2011-12-31	$9,952
Liabilities. Value of operating payables at beginning of year	2011-12-31	$34,143
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$668,260
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$410,168
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$-258,092
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$1,233,150
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$1,197,769
Income. Interest from US Government securities	2011-12-31	$3,659
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$305,900
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$291,892
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$291,892
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-12-31	$586
Expenses. Payments to insurance carriers foe the provision of benefits	2011-12-31	$420,714
Asset value of US Government securities at end of year	2011-12-31	$50,447
Asset value of US Government securities at beginning of year	2011-12-31	$103,719
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-2,683
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$10,822,531
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$14,108,872
Contract administrator fees	2011-12-31	$81,078
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2011-12-31	No
Liabilities. Value of benefit claims payable at end of year	2011-12-31	$1,272,000
Liabilities. Value of benefit claims payable at beginning of year	2011-12-31	$1,943,000
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	No
Opinion of an independent qualified public accountant for this plan	2011-12-31	Unqualified
Accountancy firm name	2011-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2011-12-31	450250958
2010 : FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2010 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2010-12-31	$-3,125
Total unrealized appreciation/depreciation of assets	2010-12-31	$-3,125
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$1,977,143
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$1,869,181
Total income from all sources (including contributions)	2010-12-31	$14,584,002
Total of all expenses incurred	2010-12-31	$15,061,783
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$14,480,286
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$14,445,961
Value of total assets at end of year	2010-12-31	$1,719,051
Value of total assets at beginning of year	2010-12-31	$2,088,870
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$581,497
Total interest from all sources	2010-12-31	$5,962
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$42,057
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2010-12-31	$42,057
Administrative expenses professional fees incurred	2010-12-31	$467,870
Was this plan covered by a fidelity bond	2010-12-31	No
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$3,299,007
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$406,633
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$125,671
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$122,254
Administrative expenses (other) incurred	2010-12-31	$5,833
Liabilities. Value of operating payables at end of year	2010-12-31	$34,143
Liabilities. Value of operating payables at beginning of year	2010-12-31	$30,395
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$-477,781
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$-258,092
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$219,689
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$1,197,769
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$1,483,690
Income. Interest from US Government securities	2010-12-31	$5,125
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$291,892
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$376,082
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$376,082
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$837
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$388,528
Asset value of US Government securities at end of year	2010-12-31	$103,719
Asset value of US Government securities at beginning of year	2010-12-31	$106,844
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$93,147
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$10,740,321
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$14,091,758
Contract administrator fees	2010-12-31	$107,794
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2010-12-31	No
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$1,943,000
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$1,838,786
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	No
Opinion of an independent qualified public accountant for this plan	2010-12-31	Unqualified
Accountancy firm name	2010-12-31	EIDE BAILLY LLP
Accountancy firm EIN	2010-12-31	450250958

Form 5500 Responses for FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN

2022: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT 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 – Trust	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 - Trust	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT 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 – Trust	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 - Trust	Yes
2017: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: FIRST INTERSTATE BANCSYSTEM INC GROUP HEALTH BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	12
Insurance contract or identification number 70386 Number of Individuals Covered 375 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 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 $59,486 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	1
Insurance contract or identification number 70386 Number of Individuals Covered 3149 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $177,443 Total amount of fees paid to insurance company USD $592 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 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 $414,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $137,634 Insurance broker organization code? 3 Amount paid for insurance broker fees 592 Additional information about fees paid to insurance broker THIRD PARTY ADMINISTRATION FEES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 2629 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	3
Insurance contract or identification number 70386 Number of Individuals Covered 461 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 CRITICAL ILLNESS 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 $119,704 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	4
Insurance contract or identification number 70386 Number of Individuals Covered 912 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 VOLUNTARY AD&D 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 $30,915 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	5
Insurance contract or identification number 70386 Number of Individuals Covered 307 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 HOSPITAL INDEMNITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $51,197 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	6
Insurance contract or identification number 70386 Number of Individuals Covered 1173 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 VOLUNTARY LIFE INSURANCE 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 $456,349 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	7
Insurance contract or identification number 70386 Number of Individuals Covered 3149 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $86,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	8
Insurance contract or identification number 70386 Number of Individuals Covered 625 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 VOLUNTARY DEP LIFESPOUSE/FAM 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 $161,269 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	9
Insurance contract or identification number 70386 Number of Individuals Covered 3149 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 BASIC DEP LIFE SPOUSE/FAM 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 $24,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	10
Insurance contract or identification number 70386 Number of Individuals Covered 546 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 VOLUNTARY DEP LIFE CHILD 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 $13,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	11
Insurance contract or identification number 70386 Number of Individuals Covered 2887 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 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 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 $543,695 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	5
Insurance contract or identification number 70386 Number of Individuals Covered 103 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 HOSPITAL INDEMNITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,925 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	4
Insurance contract or identification number 70386 Number of Individuals Covered 496 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 VOLUNTARY AD&D 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 $18,058 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	3
Insurance contract or identification number 70386 Number of Individuals Covered 170 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 CRITICAL ILLNESS 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 $57,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 1782 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	1
Insurance contract or identification number 70386 Number of Individuals Covered 1999 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $102,088 Total amount of fees paid to insurance company USD $393 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 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 $272,944 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $94,375 Insurance broker organization code? 3 Amount paid for insurance broker fees 393 Additional information about fees paid to insurance broker THIRD PARTY ADMINISTRATION FEES
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	6
Insurance contract or identification number 70386 Number of Individuals Covered 723 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 VOLUNTARY LIFE INSURANCE 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 $340,237 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	7
Insurance contract or identification number 70386 Number of Individuals Covered 1999 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 AD&D 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 $57,315 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	8
Insurance contract or identification number 70386 Number of Individuals Covered 379 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 VOLUNTARY DEP LIFESPOUSE/FAM 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 $119,889 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	9
Insurance contract or identification number 70386 Number of Individuals Covered 1999 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 BASIC DEP LIFE SPOUSE/FAM 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 $16,255 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	10
Insurance contract or identification number 70386 Number of Individuals Covered 300 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 VOLUNTARY DEP LIFE CHILD 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 $7,397 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	11
Insurance contract or identification number 70386 Number of Individuals Covered 1876 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 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 $382,642 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	70386
Policy instance	12
Insurance contract or identification number 70386 Number of Individuals Covered 125 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 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 $23,843 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	1
Insurance contract or identification number 602283 Number of Individuals Covered 2239 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $65,203 Total amount of fees paid to insurance company USD $12,339 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 AD&D 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 $705,089 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65,203 Amount paid for insurance broker fees 12339 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 1837 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0661116
Policy instance	3
Insurance contract or identification number R0661116 Number of Individuals Covered 324 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $16,630 Total amount of fees paid to insurance company USD $389 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 GCIEE, GRPACCVO AND GRPHSPVO 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 $121,226 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,037 Amount paid for insurance broker fees 389 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	607063
Policy instance	4
Insurance contract or identification number 607063 Number of Individuals Covered 678 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $69,304 Total amount of fees paid to insurance company USD $8,085 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 LIFESTYLE AD&D AND LIFESTYLE LIFE 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 $427,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69,304 Amount paid for insurance broker fees 8085 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	5
Insurance contract or identification number 148627 Number of Individuals Covered 71 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,175 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 GROUP LONG TERM CARE 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 $28,900 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,175 Insurance broker organization code? 3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	NWES0007000
Policy instance	5
Insurance contract or identification number NWES0007000 Number of Individuals Covered 1911 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 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 $1,372,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	607063
Policy instance	4
Insurance contract or identification number 607063 Number of Individuals Covered 594 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $63,316 Total amount of fees paid to insurance company USD $8,442 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 LIFESTYLE AD&D AND LIFESTYLE LIFE 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 $422,108 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63,316 Amount paid for insurance broker fees 8442 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0661116
Policy instance	3
Insurance contract or identification number R0661116 Number of Individuals Covered 373 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $23,534 Total amount of fees paid to insurance company USD $1,084 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 GCIEE, GRPACCVO AND GRPHSPVO 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 $135,404 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,940 Amount paid for insurance broker fees 1015 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 1714 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	1
Insurance contract or identification number 602283 Number of Individuals Covered 2154 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $63,219 Total amount of fees paid to insurance company USD $13,663 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 AD&D 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 $683,126 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63,219 Amount paid for insurance broker fees 13663 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	6
Insurance contract or identification number 30035757 Number of Individuals Covered 1584 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 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? 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	0011211413
Policy instance	5
Insurance contract or identification number 0011211413 Number of Individuals Covered 377 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $34,840 Total amount of fees paid to insurance company USD $2,738 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 GCIEE, GRPACCVO, GRPHSPVO 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 $146,124 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,303 Amount paid for insurance broker fees 1367 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	607063
Policy instance	4
Insurance contract or identification number 607063 Number of Individuals Covered 674 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $63,997 Total amount of fees paid to insurance company USD $9,831 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 LIFESTYLE ADD, LIFESTYLE LIFE 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 $426,644 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63,997 Amount paid for insurance broker fees 9831 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
AMERICAN ALTERNATIVE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 19720 )
Policy contract number	33A2ES000054500
Policy instance	3
Insurance contract or identification number 33A2ES000054500 Number of Individuals Covered 1882 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 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? 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 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 $1,343,794 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283 0001
Policy instance	2
Insurance contract or identification number 602283 0001 Number of Individuals Covered 2153 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $51,281 Total amount of fees paid to insurance company USD $10,915 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 AD&D 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 $579,260 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $51,281 Amount paid for insurance broker fees 10915 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283 0003
Policy instance	1
Insurance contract or identification number 602283 0003 Number of Individuals Covered 37 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $679 Total amount of fees paid to insurance company USD $102 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 AD&D 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 $5,101 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $679 Amount paid for insurance broker fees 102 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	1
Insurance contract or identification number 602283 Number of Individuals Covered 1682 Insurance policy start date 2017-01-01 Insurance policy end date 2018-01-01 Total amount of commissions paid to insurance broker USD $7,400 Total amount of fees paid to insurance company USD $617 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $492,297 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,400 Amount paid for insurance broker fees 617 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 1097 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	4
Insurance contract or identification number 148627 Number of Individuals Covered 48 Insurance policy start date 2017-01-01 Insurance policy end date 2018-01-01 Total amount of commissions paid to insurance broker USD $2,515 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided GROUP LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $24,015 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,515 Insurance broker name PAYNEWEST INSURANCE INC
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	405741
Policy instance	3
Insurance contract or identification number 405741 Number of Individuals Covered 1374 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $993,008 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3 Insurance broker name INTERMOUNTAIN UNDERWRITERS INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	1
Insurance contract or identification number 602283 Number of Individuals Covered 1719 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $55,865 Total amount of fees paid to insurance company USD $7,449 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $893,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,865 Amount paid for insurance broker fees 7449 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	2
Insurance contract or identification number 30035757 Number of Individuals Covered 1005 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 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number	ERR1156-15
Policy instance	4
Insurance contract or identification number ERR1156-15 Number of Individuals Covered 1405 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 Welfare Benefit Premiums Paid to Carrier USD $703,428 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	3
Insurance contract or identification number 148627 Number of Individuals Covered 29 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,483 Total amount of fees paid to insurance company USD $496 Other welfare benefits provided GROUP LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $23,356 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,483 Amount paid for insurance broker fees 496 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	3
Insurance contract or identification number 30035757 Number of Individuals Covered 953 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	1
Insurance contract or identification number 602283 Number of Individuals Covered 1696 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $55,929 Total amount of fees paid to insurance company USD $13,848 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $841,003 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,929 Amount paid for insurance broker fees 13848 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract number	MT-400065-9999
Policy instance	2
Insurance contract or identification number MT-400065-9999 Number of Individuals Covered 1298 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $698,635 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	4
Insurance contract or identification number 148627 Number of Individuals Covered 34 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,261 Total amount of fees paid to insurance company USD $452 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided GROUP LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $22,709 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,261 Amount paid for insurance broker fees 452 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30035757
Policy instance	5
Insurance contract or identification number 30035757 Number of Individuals Covered 901 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract number	MT-400065-9999
Policy instance	4
Insurance contract or identification number MT-400065-9999 Number of Individuals Covered 1306 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $475,935 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	602283
Policy instance	3
Insurance contract or identification number 602283 Number of Individuals Covered 1622 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $23,444 Total amount of fees paid to insurance company USD $7,815 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $377,164 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,444 Amount paid for insurance broker fees 7815 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name PAYNE WEST INSURANCE INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H36999
Policy instance	2
Insurance contract or identification number H36999 Number of Individuals Covered 1373 Insurance policy start date 2013-01-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $32,268 Total amount of fees paid to insurance company USD $5,568 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $215,117 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,268 Amount paid for insurance broker fees 5568 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H34977
Policy instance	1
Insurance contract or identification number H34977 Number of Individuals Covered 5106 Insurance policy start date 2013-01-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $5,902 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $232,803 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 5902 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	6
Insurance contract or identification number 148627 Number of Individuals Covered 28 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,961 Total amount of fees paid to insurance company USD $391 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided GROUP LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $21,108 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,961 Amount paid for insurance broker fees 391 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H34977
Policy instance	1
Insurance contract or identification number H34977 Number of Individuals Covered 5206 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $2,518 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $392,509 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 2518 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	949-1754
Policy instance	4
Insurance contract or identification number 949-1754 Number of Individuals Covered 1384 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $9,462 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $473,088 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 9462 Additional information about fees paid to insurance broker SERVICE FEES Insurance broker organization code? 5 Insurance broker name ALLEGIANCE BENEFIT MANAGEMENT
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	3
Insurance contract or identification number 148627 Number of Individuals Covered 26 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $2,232 Total amount of fees paid to insurance company USD $279 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $22,461 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,232 Amount paid for insurance broker fees 279 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ASSUREX
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H36999
Policy instance	2
Insurance contract or identification number H36999 Number of Individuals Covered 1447 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $55,294 Total amount of fees paid to insurance company USD $2,297 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $368,626 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,294 Amount paid for insurance broker fees 2297 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H34977
Policy instance	1
Insurance contract or identification number H34977 Number of Individuals Covered 1680 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $15,050 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $387,922 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	5
Insurance contract or identification number 148627 Number of Individuals Covered 22 Insurance policy start date 2010-07-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $1,024 Total amount of fees paid to insurance company USD $257 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $8,535 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	299-6248
Policy instance	4
Insurance contract or identification number 299-6248 Number of Individuals Covered 1396 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $420,885 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	148627
Policy instance	3
Insurance contract or identification number 148627 Number of Individuals Covered 22 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $2,002 Total amount of fees paid to insurance company USD $377 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $21,387 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H36999
Policy instance	2
Insurance contract or identification number H36999 Number of Individuals Covered 613 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $52,950 Total amount of fees paid to insurance company USD $9,399 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $353,000 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H34977
Policy instance	2
Insurance contract or identification number H34977 Number of Individuals Covered 1754 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $59,314 Total amount of fees paid to insurance company USD $6,765 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $613,866 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,937 Insurance broker organization code? 3 Amount paid for insurance broker fees 6765 Additional information about fees paid to insurance broker BONUS Insurance broker name PAYNE FINANCIAL GROUP INC
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	135792
Policy instance	3
Insurance contract or identification number 135792 Number of Individuals Covered 38 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,557 Total amount of fees paid to insurance company USD $118 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,585 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,557 Insurance broker organization code? 3 Amount paid for insurance broker fees 118 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker name ASSUREX INTERNATIONAL
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number	H36999
Policy instance	4
Insurance contract or identification number H36999 Number of Individuals Covered 630 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $54,389 Total amount of fees paid to insurance company USD $3,122 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $362,592 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,219 Amount paid for insurance broker fees 3122 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name PAYNE FINANCIAL GROUP INC
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	16-006791-000
Policy instance	1
Insurance contract or identification number 16-006791-000 Number of Individuals Covered 1493 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $8,962 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $350,735 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 8962 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name INTERMOUNTAIN UNDERWRITERS INC

Potentially related plans

• FIRST INTERSTATE PROPERTIES PROFIT SHARING PLAN [EIN = 341905390]
• FIRST INTERSTATE BANCSYSTEM INC FLEX BENEFITS PLAN [EIN = 810331432]