401k Plan data: EMPLOYEE DISABILITY PLAN plan

EMPLOYEE DISABILITY PLAN 401k Plan overview

Plan Name	EMPLOYEE DISABILITY PLAN
Plan identification number	504

EMPLOYEE DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BLUE CROSS & BLUE SHIELD OF ARIZONA, INC. has sponsored the creation of one or more 401k plans.

Company Name: BLUE CROSS & BLUE SHIELD OF ARIZONA, INC.

Employer identification number (EIN): 860004538

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2022-01-01
504 2021-01-01
504 2020-01-01
504 2019-01-01
504 2018-01-01
504 2017-01-01 GREG WELLS, CHIEF HR OFFICER
504 2016-01-01 GREG WELLS, VICE PRESIDENT
504 2015-01-01 GREG WELLS, VICE PRESIDENT
504 2014-01-01 GREG WELLS, VICE PRESIDENT
504 2013-01-01 GREG WELLS, VICE PRESIDENT
504 2012-01-01 GREG WELLS, VICE PRESIDENT
504 2011-01-01 GREG WELLS, VICE PRESIDENT
504 2010-01-01 GREG WELLS, VICE PRESIDENT
504 2009-01-01 GREG WELLS, VICE PRESIDENT

Plan Statistics for EMPLOYEE DISABILITY PLAN

401k plan membership statisitcs for EMPLOYEE DISABILITY PLAN

Measure Date Value
2022: EMPLOYEE DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,109
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,676
Number of retired or separated participants receiving benefits 2022-01-01 11
Total of all active and inactive participants 2022-01-01 2,687
Total participants 2022-01-01 2,687
2021: EMPLOYEE DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,724
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,099
Number of retired or separated participants receiving benefits 2021-01-01 10
Total of all active and inactive participants 2021-01-01 2,109
Total participants 2021-01-01 2,109
2020: EMPLOYEE DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,475
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,713
Number of retired or separated participants receiving benefits 2020-01-01 11
Total of all active and inactive participants 2020-01-01 1,724
Total participants 2020-01-01 1,724
2019: EMPLOYEE DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,328
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,462
Number of retired or separated participants receiving benefits 2019-01-01 13
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 1,475
Total participants 2019-01-01 1,475
2018: EMPLOYEE DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,332
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,305
Number of retired or separated participants receiving benefits 2018-01-01 23
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 1,328
Total participants 2018-01-01 1,328
2017: EMPLOYEE DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,347
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,318
Number of retired or separated participants receiving benefits 2017-01-01 14
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 1,332
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 1,332
2016: EMPLOYEE DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,459
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,319
Number of retired or separated participants receiving benefits 2016-01-01 28
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 1,347
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 1,347
2015: EMPLOYEE DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,281
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,441
Number of retired or separated participants receiving benefits 2015-01-01 18
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 1,459
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 1,459
2014: EMPLOYEE DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,215
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,269
Number of retired or separated participants receiving benefits 2014-01-01 12
Total of all active and inactive participants 2014-01-01 1,281
Total participants 2014-01-01 1,281
2013: EMPLOYEE DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,281
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,209
Number of retired or separated participants receiving benefits 2013-01-01 6
Total of all active and inactive participants 2013-01-01 1,215
Total participants 2013-01-01 1,215
2012: EMPLOYEE DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,333
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,275
Number of retired or separated participants receiving benefits 2012-01-01 6
Total of all active and inactive participants 2012-01-01 1,281
Total participants 2012-01-01 1,281
2011: EMPLOYEE DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,469
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,326
Number of retired or separated participants receiving benefits 2011-01-01 7
Total of all active and inactive participants 2011-01-01 1,333
Total participants 2011-01-01 1,333
2010: EMPLOYEE DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 1,461
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,447
Number of retired or separated participants receiving benefits 2010-01-01 22
Total of all active and inactive participants 2010-01-01 1,469
Total participants 2010-01-01 1,469
2009: EMPLOYEE DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,401
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,436
Number of retired or separated participants receiving benefits 2009-01-01 25
Total of all active and inactive participants 2009-01-01 1,461
Total participants 2009-01-01 1,461

Measure	Date	Value
2022: EMPLOYEE DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,109
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,676
Number of retired or separated participants receiving benefits	2022-01-01	11
Total of all active and inactive participants	2022-01-01	2,687
Total participants	2022-01-01	2,687
2021: EMPLOYEE DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,724
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,099
Number of retired or separated participants receiving benefits	2021-01-01	10
Total of all active and inactive participants	2021-01-01	2,109
Total participants	2021-01-01	2,109
2020: EMPLOYEE DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,475
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,713
Number of retired or separated participants receiving benefits	2020-01-01	11
Total of all active and inactive participants	2020-01-01	1,724
Total participants	2020-01-01	1,724
2019: EMPLOYEE DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,328
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,462
Number of retired or separated participants receiving benefits	2019-01-01	13
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	1,475
Total participants	2019-01-01	1,475
2018: EMPLOYEE DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,332
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,305
Number of retired or separated participants receiving benefits	2018-01-01	23
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	1,328
Total participants	2018-01-01	1,328
2017: EMPLOYEE DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,347
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,318
Number of retired or separated participants receiving benefits	2017-01-01	14
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,332
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	1,332
2016: EMPLOYEE DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,459
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,319
Number of retired or separated participants receiving benefits	2016-01-01	28
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	1,347
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	1,347
2015: EMPLOYEE DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,281
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,441
Number of retired or separated participants receiving benefits	2015-01-01	18
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	1,459
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	1,459
2014: EMPLOYEE DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,215
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,269
Number of retired or separated participants receiving benefits	2014-01-01	12
Total of all active and inactive participants	2014-01-01	1,281
Total participants	2014-01-01	1,281
2013: EMPLOYEE DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,281
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,209
Number of retired or separated participants receiving benefits	2013-01-01	6
Total of all active and inactive participants	2013-01-01	1,215
Total participants	2013-01-01	1,215
2012: EMPLOYEE DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,333
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,275
Number of retired or separated participants receiving benefits	2012-01-01	6
Total of all active and inactive participants	2012-01-01	1,281
Total participants	2012-01-01	1,281
2011: EMPLOYEE DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,469
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,326
Number of retired or separated participants receiving benefits	2011-01-01	7
Total of all active and inactive participants	2011-01-01	1,333
Total participants	2011-01-01	1,333
2010: EMPLOYEE DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	1,461
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,447
Number of retired or separated participants receiving benefits	2010-01-01	22
Total of all active and inactive participants	2010-01-01	1,469
Total participants	2010-01-01	1,469
2009: EMPLOYEE DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,401
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,436
Number of retired or separated participants receiving benefits	2009-01-01	25
Total of all active and inactive participants	2009-01-01	1,461
Total participants	2009-01-01	1,461

Form 5500 Responses for EMPLOYEE DISABILITY PLAN

2022: EMPLOYEE DISABILITY PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: EMPLOYEE DISABILITY PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EMPLOYEE DISABILITY PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EMPLOYEE DISABILITY PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EMPLOYEE DISABILITY PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EMPLOYEE DISABILITY PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: EMPLOYEE DISABILITY PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EMPLOYEE DISABILITY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYEE DISABILITY PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYEE DISABILITY PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYEE DISABILITY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYEE DISABILITY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: EMPLOYEE DISABILITY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: EMPLOYEE DISABILITY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

007626

Policy instance

Insurance contract or identification number	007626
Number of Individuals Covered	2676
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $41,695
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $833,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	41695
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	2
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9906-7084

Policy instance

Insurance contract or identification number	9906-7084
Number of Individuals Covered	2666
Insurance policy start date	2021-06-01
Insurance policy end date	2022-06-01
Total amount of commissions paid to insurance broker	USD $608
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Insurance broker organization code?	3

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

007626

Policy instance

Insurance contract or identification number	007626
Number of Individuals Covered	2672
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $58,354
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,167,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,354
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	3
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	110
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

007626

Policy instance

Insurance contract or identification number	007626
Number of Individuals Covered	2005
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $33,335
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $666,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	33335
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	2
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	4
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

007626

Policy instance

Insurance contract or identification number	007626
Number of Individuals Covered	2005
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $44,017
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $880,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	44017
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	110
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
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

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1701
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,078
Total amount of fees paid to insurance company	USD $100
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $485,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $4,061

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1701
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $26,708
Total amount of fees paid to insurance company	USD $190
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $921,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $7,704

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	103
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $608
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1450
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $22,610
Total amount of fees paid to insurance company	USD $5,872
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $489,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	149
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $18,402

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1450
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $39,427
Total amount of fees paid to insurance company	USD $10,239
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $853,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	259
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $32,089

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	9
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	4
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	87
Insurance policy start date	2017-06-01
Insurance policy end date	2018-06-01
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1293
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $73,552
Total amount of fees paid to insurance company	USD $226
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $804,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,479
Insurance broker organization code?	3
Amount paid for insurance broker fees	226
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

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1294
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $42,156
Total amount of fees paid to insurance company	USD $129
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $461,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,176
Insurance broker organization code?	3
Amount paid for insurance broker fees	129
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $528
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	528
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $1,095
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1095
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1255
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $26,020
Total amount of fees paid to insurance company	USD $133
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $448,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,020
Insurance broker organization code?	3
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	80
Insurance policy start date	2016-06-01
Insurance policy end date	2017-06-01
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	WILLIS OF ARIZONA, INC.

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

52712

Policy instance

Insurance contract or identification number	52712
Number of Individuals Covered	1255
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $45,408
Total amount of fees paid to insurance company	USD $233
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $782,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,408
Insurance broker organization code?	3
Amount paid for insurance broker fees	233
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1318
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7
Total amount of fees paid to insurance company	USD $11,349
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,770
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	11349
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	WILLIS INSURANCE SVCS OF CA

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1318
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11
Total amount of fees paid to insurance company	USD $5,438
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,392
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	5438
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	WILLIS INSURANCE SVCS OF CA

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	4
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	4
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1441
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,090
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $288,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,090
Insurance broker organization code?	3
Insurance broker name	WILLIS OF ARIZONA INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

210043

Policy instance

Insurance contract or identification number	210043
Number of Individuals Covered	3
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,854
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

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1441
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $27,266
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $595,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,266
Insurance broker organization code?	3
Insurance broker name	WILLIS OF ARIZONA INC

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	85
Insurance policy start date	2014-06-01
Insurance policy end date	2015-06-01
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
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

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	12
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,913
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

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	28
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,146
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

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	5
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

210043

Policy instance

Insurance contract or identification number	210043
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1269
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,076
Total amount of fees paid to insurance company	USD $8,493
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $255,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,076
Insurance broker organization code?	3
Amount paid for insurance broker fees	8493
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	WILLIS INSURANCE SVCS OF CA

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

Policy contract number

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	28
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,790
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

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

402674G

Policy instance

Insurance contract or identification number	402674G
Number of Individuals Covered	1269
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $29,242
Total amount of fees paid to insurance company	USD $17,432
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $535,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,242
Insurance broker organization code?	3
Amount paid for insurance broker fees	17432
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	WILLIS INSURANCE SVCS OF CA

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000099067084

Policy instance

Insurance contract or identification number	000099067084
Number of Individuals Covered	85
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $608
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Insurance broker organization code?	3
Insurance broker name	WILLIS OF ARIZONA, INC

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,655
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

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,661
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

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	32
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	15
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,462
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

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1209
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $53,701
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,701
Insurance broker organization code?	3
Insurance broker name	WILLIS OF AZ INC

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1209
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $37,315
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,315
Insurance broker organization code?	3
Insurance broker name	WILLIS OF AZ INC

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

Policy contract number

675730G

Policy instance

Insurance contract or identification number	675730G
Number of Individuals Covered	5
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	13
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,631
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

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	31
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,357
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

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	13
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	20
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,426
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

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1275
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $33,836
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,836
Insurance broker organization code?	3
Insurance broker name	WILLIS OF AZ INC

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1275
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $48,603
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,603
Insurance broker organization code?	3
Insurance broker name	WILLIS OF AZ INC

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	6
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,038
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

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	28
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	22
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1326
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $53,662
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

152459

Policy instance

Insurance contract or identification number	152459
Number of Individuals Covered	1326
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $37,418
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

102083

Policy instance

Insurance contract or identification number	102083
Number of Individuals Covered	1
Insurance policy start date	2011-10-01
Insurance policy end date	2012-02-29
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	7
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,769
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

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730-GRH

Policy instance

Insurance contract or identification number	675730-GRH
Number of Individuals Covered	1447
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53,905
Total amount of fees paid to insurance company	USD $2,673
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $768,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,905
Amount paid for insurance broker fees	2673
Additional information about fees paid to insurance broker	0 FEES
Insurance broker organization code?	3
Insurance broker name	CSA GENERAL INSURANCE AGENCY, INC.

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F000051

Policy instance

Insurance contract or identification number	F000051
Number of Individuals Covered	9
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-240524

Policy instance

Insurance contract or identification number	APM-240524
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

APM-223814

Policy instance

Insurance contract or identification number	APM-223814
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,184
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

2918600

Policy instance

Insurance contract or identification number	2918600
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,038
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

GS0112

Policy instance

Insurance contract or identification number	GS0112
Number of Individuals Covered	28
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDAMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69515 )

Policy contract number

635-110

Policy instance

Insurance contract or identification number	635-110
Number of Individuals Covered	27
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

675730-GLT

Policy instance

Insurance contract or identification number	675730-GLT
Number of Individuals Covered	1460
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $38,091
Total amount of fees paid to insurance company	USD $1,969
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $543,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,091
Amount paid for insurance broker fees	1969
Additional information about fees paid to insurance broker	0 FEES
Insurance broker organization code?	3
Insurance broker name	CSA GENERAL INSURANCE AGENCY, INC.

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

Policy contract number

56799

Policy instance

Insurance contract or identification number	56799
Number of Individuals Covered	9
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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EMPLOYEE DISABILITY & GROUP TERM LIFE INSURANCE PLAN [EIN = 311024403]

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Company Name:	BLUE CROSS & BLUE SHIELD OF ARIZONA, INC.
Employer identification number (EIN):	860004538
NAIC Classification:	524140