401k Plan data: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN plan

AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

AMPERITY, INC. HEALTH AND WELFARE 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

AMPERITY, INC. has sponsored the creation of one or more 401k plans.

Company Name: AMPERITY, INC.

Employer identification number (EIN): 810890699

NAIC Classification: 541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-10-01
501 2021-10-01
501 2020-10-01
501 2019-10-01 AMY PELLY 2021-04-09

Plan Statistics for AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2022: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-10-01 366
Total number of active participants reported on line 7a of the Form 5500 2022-10-01 314
Number of retired or separated participants receiving benefits 2022-10-01 16
Number of other retired or separated participants entitled to future benefits 2022-10-01 0
Total of all active and inactive participants 2022-10-01 330
2021: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 238
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 364
Number of retired or separated participants receiving benefits 2021-10-01 3
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 367
2020: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 154
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 220
Number of retired or separated participants receiving benefits 2020-10-01 1
Number of other retired or separated participants entitled to future benefits 2020-10-01 0
Total of all active and inactive participants 2020-10-01 221
2019: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 100
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 150
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 150
Number of employers contributing to the scheme 2019-10-01 0

Measure	Date	Value
2022: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-10-01	366
Total number of active participants reported on line 7a of the Form 5500	2022-10-01	314
Number of retired or separated participants receiving benefits	2022-10-01	16
Number of other retired or separated participants entitled to future benefits	2022-10-01	0
Total of all active and inactive participants	2022-10-01	330
2021: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	238
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	364
Number of retired or separated participants receiving benefits	2021-10-01	3
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	367
2020: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	154
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	220
Number of retired or separated participants receiving benefits	2020-10-01	1
Number of other retired or separated participants entitled to future benefits	2020-10-01	0
Total of all active and inactive participants	2020-10-01	221
2019: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	100
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	150
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	150
Number of employers contributing to the scheme	2019-10-01	0

Form 5500 Responses for AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN

2022: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-10-01	Type of plan entity	Single employer plan
2022-10-01	Submission has been amended	No
2022-10-01	This submission is the final filing	No
2022-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-10-01	Plan is a collectively bargained plan	No
2022-10-01	Plan funding arrangement – Insurance	Yes
2022-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-10-01	Plan benefit arrangement – Insurance	Yes
2022-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	Submission has been amended	No
2021-10-01	This submission is the final filing	No
2021-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-10-01	Plan is a collectively bargained plan	No
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	Submission has been amended	No
2020-10-01	This submission is the final filing	No
2020-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-10-01	Plan is a collectively bargained plan	No
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: AMPERITY, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	First time form 5500 has been submitted	Yes
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

GVLT0B9FM

Policy instance

Insurance contract or identification number	GVLT0B9FM
Number of Individuals Covered	133
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,479
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	VOLUNTARY LIFE AND ADD
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 $55,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2479
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30093559

Policy instance

Insurance contract or identification number	30093559
Number of Individuals Covered	309
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $1,775
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
Welfare Benefit Premiums Paid to Carrier	USD $45,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,775
Insurance broker organization code?	3

WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

AMPERITY

Policy instance

Insurance contract or identification number	AMPERITY
Number of Individuals Covered	352
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0B9FM

Policy instance

Insurance contract or identification number	GLTD0B9FM
Number of Individuals Covered	323
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,563
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 $66,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3563
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9FM

Policy instance

Insurance contract or identification number	GLUG0B9FM
Number of Individuals Covered	323
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,097
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 $39,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2097
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG0B9FM

Policy instance

Insurance contract or identification number	GUG0B9FM
Number of Individuals Covered	323
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,637
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $43,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2637
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4009852

Policy instance

Insurance contract or identification number	4009852
Number of Individuals Covered	623
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $13,574
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,967,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	13574
Additional information about fees paid to insurance broker	PREFERRED PRODUCER PROGRAM
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )

Policy contract number

13134

Policy instance

Insurance contract or identification number	13134
Number of Individuals Covered	643
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $12,487
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,487
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30093559

Policy instance

Insurance contract or identification number	30093559
Number of Individuals Covered	587
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $1,683
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
Welfare Benefit Premiums Paid to Carrier	USD $41,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,683
Insurance broker organization code?	3

WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

AMPERITY

Policy instance

Insurance contract or identification number	AMPERITY
Number of Individuals Covered	753
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0B9FM

Policy instance

Insurance contract or identification number	GLTD0B9FM
Number of Individuals Covered	364
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,252
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 $61,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1252
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9FM

Policy instance

Insurance contract or identification number	GLUG0B9FM
Number of Individuals Covered	364
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $406
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 $36,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	406
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG0B9FM

Policy instance

Insurance contract or identification number	GUG0B9FM
Number of Individuals Covered	364
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $758
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	758
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVLT0B9FM

Policy instance

Insurance contract or identification number	GVLT0B9FM
Number of Individuals Covered	141
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $216
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	VOLUNTARY LIFE AND ADD
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 $40,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVLT0B9FM

Policy instance

Insurance contract or identification number	GVLT0B9FM
Number of Individuals Covered	13
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
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	VOLUNTARY LIFE AND ADD
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUG0B9FM

Policy instance

Insurance contract or identification number	GUG0B9FM
Number of Individuals Covered	221
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $5,489
Total amount of fees paid to insurance company	USD $1,715
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,884
Insurance broker organization code?	3
Amount paid for insurance broker fees	1715
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GLUG0B9FM

Policy instance

Insurance contract or identification number	GLUG0B9FM
Number of Individuals Covered	221
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $1,640
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
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 $8,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,160
Insurance broker organization code?	3
Amount paid for insurance broker fees	393
Additional information about fees paid to insurance broker	OTHER COMPENSATION

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4009852

Policy instance

Insurance contract or identification number	4009852
Number of Individuals Covered	401
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $73,225
Total amount of fees paid to insurance company	USD $11,479
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,464,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,189
Amount paid for insurance broker fees	11479
Additional information about fees paid to insurance broker	PREFERRED PRODUCER PROGRAM
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )

Policy contract number

13134

Policy instance

Insurance contract or identification number	13134
Number of Individuals Covered	401
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $9,125
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,387
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30093559

Policy instance

Insurance contract or identification number	30093559
Number of Individuals Covered	216
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $988
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
Welfare Benefit Premiums Paid to Carrier	USD $16,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $818
Insurance broker organization code?	3

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

Policy contract number

715677

Policy instance

Insurance contract or identification number	715677
Number of Individuals Covered	46
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $1,331
Total amount of fees paid to insurance company	USD $83
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 $7,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,331
Insurance broker organization code?	3
Amount paid for insurance broker fees	83
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

AMPERITY

Policy instance

Insurance contract or identification number	AMPERITY
Number of Individuals Covered	125
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

771039

Policy instance

Insurance contract or identification number	771039
Number of Individuals Covered	72
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $1,372
Total amount of fees paid to insurance company	USD $142
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,372
Insurance broker organization code?	3
Amount paid for insurance broker fees	142
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION

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

Policy contract number

GLTD0B9FM

Policy instance

Insurance contract or identification number	GLTD0B9FM
Number of Individuals Covered	221
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $6,744
Total amount of fees paid to insurance company	USD $1,591
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 $33,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,779
Insurance broker organization code?	3
Amount paid for insurance broker fees	1591
Additional information about fees paid to insurance broker	OTHER COMPENSATION

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )

Policy contract number

13134

Policy instance

Insurance contract or identification number	13134
Number of Individuals Covered	283
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $6,554
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,554
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30093559

Policy instance

Insurance contract or identification number	30093559
Number of Individuals Covered	143
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $856
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $856
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

715677

Policy instance

Insurance contract or identification number	715677
Number of Individuals Covered	41
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $2,122
Total amount of fees paid to insurance company	USD $265
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,122
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

AMPERITY

Policy instance

Insurance contract or identification number	AMPERITY
Number of Individuals Covered	150
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $3,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

771039

Policy instance

Insurance contract or identification number	771039
Number of Individuals Covered	54
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $1,367
Total amount of fees paid to insurance company	USD $202
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,367
Amount paid for insurance broker fees	95
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9FM

Policy instance

Insurance contract or identification number	GLUG0B9FM
Number of Individuals Covered	145
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $11,822
Total amount of fees paid to insurance company	USD $2,738
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $59,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,822
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4009852

Policy instance

Insurance contract or identification number	4009852
Number of Individuals Covered	274
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $62,538
Total amount of fees paid to insurance company	USD $6,954
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,250,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,538
Amount paid for insurance broker fees	6954
Additional information about fees paid to insurance broker	PREFERRED PRODUCER PROGRAM
Insurance broker organization code?	3

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Company Name:	AMPERITY, INC.
Employer identification number (EIN):	810890699
NAIC Classification:	541600