401k Plan data: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN plan

AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN
Plan identification number	501

AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Other welfare benefit cover

401k Sponsoring company profile

AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION

Employer identification number (EIN): 860695452

NAIC Classification: 238210
NAIC Description: Electrical Contractors and Other Wiring Installation Contractors

Additional information about AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C2181525

More information about AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-11-01 ROSE MARY FARRELL
501 2015-11-01 ROSE MARY FARRELL
501 2014-11-01 ROSE MARY FARRELL
501 2013-11-01 ROSE MARY FARRELL
501 2012-11-01 ROSE MARY FARRELL
501 2011-11-01 ROSE MARY FARRELL
501 2010-11-01 ROSE MARY FARRELL
501 2009-11-01 ROSE MARY FARRELL

Plan id#	Filing Submission Date	Name of Administrator
501	2016-11-01	ROSE MARY FARRELL
501	2015-11-01	ROSE MARY FARRELL
501	2014-11-01	ROSE MARY FARRELL
501	2013-11-01	ROSE MARY FARRELL
501	2012-11-01	ROSE MARY FARRELL
501	2011-11-01	ROSE MARY FARRELL
501	2010-11-01	ROSE MARY FARRELL
501	2009-11-01	ROSE MARY FARRELL

Plan Statistics for AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN

Measure Date Value
2016: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-11-01 163
Total number of active participants reported on line 7a of the Form 5500 2016-11-01 163
Total of all active and inactive participants 2016-11-01 163
Total participants 2016-11-01 163
2015: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-11-01 138
Total number of active participants reported on line 7a of the Form 5500 2015-11-01 163
Total of all active and inactive participants 2015-11-01 163
Total participants 2015-11-01 163
2014: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-11-01 105
Total number of active participants reported on line 7a of the Form 5500 2014-11-01 138
Total of all active and inactive participants 2014-11-01 138
Total participants 2014-11-01 138
2013: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-11-01 104
Total number of active participants reported on line 7a of the Form 5500 2013-11-01 105
Total of all active and inactive participants 2013-11-01 105
Total participants 2013-11-01 105
2012: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-11-01 100
Total number of active participants reported on line 7a of the Form 5500 2012-11-01 104
Total of all active and inactive participants 2012-11-01 104
Total participants 2012-11-01 104
2011: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-11-01 96
Total number of active participants reported on line 7a of the Form 5500 2011-11-01 100
Total of all active and inactive participants 2011-11-01 100
Total participants 2011-11-01 100
2010: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-11-01 91
Total number of active participants reported on line 7a of the Form 5500 2010-11-01 96
Total of all active and inactive participants 2010-11-01 96
Total participants 2010-11-01 96
2009: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-11-01 87
Total number of active participants reported on line 7a of the Form 5500 2009-11-01 91
Total of all active and inactive participants 2009-11-01 91
Total participants 2009-11-01 91

Measure	Date	Value
2016: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-11-01	163
Total number of active participants reported on line 7a of the Form 5500	2016-11-01	163
Total of all active and inactive participants	2016-11-01	163
Total participants	2016-11-01	163
2015: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-11-01	138
Total number of active participants reported on line 7a of the Form 5500	2015-11-01	163
Total of all active and inactive participants	2015-11-01	163
Total participants	2015-11-01	163
2014: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-11-01	105
Total number of active participants reported on line 7a of the Form 5500	2014-11-01	138
Total of all active and inactive participants	2014-11-01	138
Total participants	2014-11-01	138
2013: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-11-01	104
Total number of active participants reported on line 7a of the Form 5500	2013-11-01	105
Total of all active and inactive participants	2013-11-01	105
Total participants	2013-11-01	105
2012: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-11-01	100
Total number of active participants reported on line 7a of the Form 5500	2012-11-01	104
Total of all active and inactive participants	2012-11-01	104
Total participants	2012-11-01	104
2011: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-11-01	96
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	100
Total of all active and inactive participants	2011-11-01	100
Total participants	2011-11-01	100
2010: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-11-01	91
Total number of active participants reported on line 7a of the Form 5500	2010-11-01	96
Total of all active and inactive participants	2010-11-01	96
Total participants	2010-11-01	96
2009: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-11-01	87
Total number of active participants reported on line 7a of the Form 5500	2009-11-01	91
Total of all active and inactive participants	2009-11-01	91
Total participants	2009-11-01	91

Form 5500 Responses for AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN

2016: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-11-01	Type of plan entity	Single employer plan
2016-11-01	Submission has been amended	No
2016-11-01	This submission is the final filing	No
2016-11-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-11-01	Plan is a collectively bargained plan	No
2016-11-01	Plan funding arrangement – Insurance	Yes
2016-11-01	Plan benefit arrangement – Insurance	Yes
2015: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-11-01	Type of plan entity	Single employer plan
2015-11-01	Submission has been amended	No
2015-11-01	This submission is the final filing	No
2015-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-11-01	Plan is a collectively bargained plan	No
2015-11-01	Plan funding arrangement – Insurance	Yes
2015-11-01	Plan benefit arrangement – Insurance	Yes
2014: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-11-01	Type of plan entity	Single employer plan
2014-11-01	First time form 5500 has been submitted	Yes
2014-11-01	Submission has been amended	No
2014-11-01	This submission is the final filing	No
2014-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-11-01	Plan is a collectively bargained plan	No
2014-11-01	Plan funding arrangement – Insurance	Yes
2014-11-01	Plan benefit arrangement – Insurance	Yes
2013: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-11-01	Type of plan entity	Single employer plan
2013-11-01	Submission has been amended	No
2013-11-01	This submission is the final filing	No
2013-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-11-01	Plan is a collectively bargained plan	No
2013-11-01	Plan funding arrangement – Insurance	Yes
2013-11-01	Plan benefit arrangement – Insurance	Yes
2012: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-11-01	Type of plan entity	Single employer plan
2012-11-01	Submission has been amended	No
2012-11-01	This submission is the final filing	No
2012-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-11-01	Plan is a collectively bargained plan	No
2012-11-01	Plan funding arrangement – Insurance	Yes
2012-11-01	Plan benefit arrangement – Insurance	Yes
2011: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-11-01	Type of plan entity	Single employer plan
2011-11-01	Submission has been amended	No
2011-11-01	This submission is the final filing	No
2011-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-11-01	Plan is a collectively bargained plan	No
2011-11-01	Plan funding arrangement – Insurance	Yes
2011-11-01	Plan benefit arrangement – Insurance	Yes
2010: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-11-01	Type of plan entity	Single employer plan
2010-11-01	Submission has been amended	No
2010-11-01	This submission is the final filing	No
2010-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-11-01	Plan is a collectively bargained plan	No
2010-11-01	Plan funding arrangement – Insurance	Yes
2010-11-01	Plan benefit arrangement – Insurance	Yes
2009: AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-11-01	Type of plan entity	Single employer plan
2009-11-01	Submission has been amended	No
2009-11-01	This submission is the final filing	No
2009-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-11-01	Plan is a collectively bargained plan	No
2009-11-01	Plan funding arrangement – Insurance	Yes
2009-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

33158

Policy instance

Insurance contract or identification number	33158
Number of Individuals Covered	141
Insurance policy start date	2016-11-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $7,776
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	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 $154,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,776
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BENEFIT COMMERCE GROUP

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	149
Insurance policy start date	2016-11-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $2,131
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,131
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

KM05940140

Policy instance

Insurance contract or identification number	KM05940140
Number of Individuals Covered	499
Insurance policy start date	2016-11-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $2,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BENEFIT COMMERCE GROUP

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

21246

Policy instance

Insurance contract or identification number	21246
Number of Individuals Covered	92
Insurance policy start date	2016-11-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $216
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $216
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

21246

Policy instance

Insurance contract or identification number	21246
Number of Individuals Covered	86
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $1,178
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,178
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	140
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $11,661
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $145,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,661
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

906486

Policy instance

Insurance contract or identification number	906486
Number of Individuals Covered	286
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $51,215
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,087,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	51215
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	SERENE JOY PRICE

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

Policy contract number

303034

Policy instance

Insurance contract or identification number	303034
Number of Individuals Covered	164
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $996
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	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 $9,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $996
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE PRICE

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

Policy contract number

303034

Policy instance

Insurance contract or identification number	303034
Number of Individuals Covered	163
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $857
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $9,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $857
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE PRICE

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

Policy contract number

585514

Policy instance

Insurance contract or identification number	585514
Number of Individuals Covered	297
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $52,983
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,115,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,983
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE JOY PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	81
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,331
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,305
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	135
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $11,414
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $142,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,414
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	74
Insurance policy start date	2014-10-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $89
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	74
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $995
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $995
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	124
Insurance policy start date	2014-10-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $870
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $870
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

585514

Policy instance

Insurance contract or identification number	585514
Number of Individuals Covered	288
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $45,928
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $966,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,928
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE JOY PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	123
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $8,948
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $120,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,948
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

585514

Policy instance

Insurance contract or identification number	585514
Number of Individuals Covered	247
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $43,788
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $805,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,788
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE JOY PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	63
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $1,079
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,079
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	104
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $9,360
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $108,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,360
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	46
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $503
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $503
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

20246

Policy instance

Insurance contract or identification number	20246
Number of Individuals Covered	54
Insurance policy start date	2012-03-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $465
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $465
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	100
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $7,787
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $97,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,787
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

585514

Policy instance

Insurance contract or identification number	585514
Number of Individuals Covered	132
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $41,585
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $768,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,585
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE JOY PRICE

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

21689

Policy instance

Insurance contract or identification number	21689
Number of Individuals Covered	96
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $34,287
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	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 $685,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,287
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCE PLUS INC

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

Policy contract number

MA021689

Policy instance

Insurance contract or identification number	MA021689
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $2,163
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $8,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,163
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CSA GENERAL INSURANCE AGENCY

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	95
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $7,785
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $97,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,785
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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

Policy contract number

MA021689

Policy instance

Insurance contract or identification number	MA021689
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $1,222
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $4,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,222
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CSA GENERAL INSURANCE AGENCY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

21689

Policy instance

Insurance contract or identification number	21689
Number of Individuals Covered	91
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $31,518
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $630,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,518
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCE PLUS INC

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

55521 03909

Policy instance

Insurance contract or identification number	55521 03909
Number of Individuals Covered	87
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $6,945
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $86,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,945
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SERENE J PRICE

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Company Name:	AMERICAN FIRE EQUIPMENT SALES AND SERVICE CORPORATION
Employer identification number (EIN):	860695452
NAIC Classification:	238210
NAIC Description:	Electrical Contractors and Other Wiring Installation Contractors

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C2181525