401k Plan data: LES OLSON COMPANY PLAN plan

LES OLSON COMPANY PLAN 401k Plan overview

Plan Name	LES OLSON COMPANY PLAN
Plan identification number	501

LES OLSON COMPANY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

LES OLSON COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: LES OLSON COMPANY, INC.

Employer identification number (EIN): 870324153

NAIC Classification: 453210
NAIC Description: Office Supplies and Stationery Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LES OLSON COMPANY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 JAMES OLSON JAMES OLSON 2018-08-29
501 2016-01-01 JAMES OLSON JAMES OLSON 2017-10-06
501 2015-01-01 LISA THALLER JIM OLSON 2016-09-27
501 2014-01-01 LISA THALLER JIM OLSON 2015-10-14
501 2013-01-01 LISA THALLER JIM OLSON 2014-07-30
501 2012-01-01 LISA THALLER JIM OLSON 2013-09-06
501 2011-01-01 LISA THALLER JIM OLSON 2012-10-10
501 2009-01-01 S DAVID JACKSON
501 2009-01-01 LISA THALLER JIM OLSON 2011-03-01
501 2009-01-01 MIKE HAMMER
501 2009-01-01 MIKE HAMMER
501 2009-01-01 LISA THALLER JIM OLSON 2011-03-02

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	JAMES OLSON	JAMES OLSON	2018-08-29
501	2016-01-01	JAMES OLSON	JAMES OLSON	2017-10-06
501	2015-01-01	LISA THALLER	JIM OLSON	2016-09-27
501	2014-01-01	LISA THALLER	JIM OLSON	2015-10-14
501	2013-01-01	LISA THALLER	JIM OLSON	2014-07-30
501	2012-01-01	LISA THALLER	JIM OLSON	2013-09-06
501	2011-01-01	LISA THALLER	JIM OLSON	2012-10-10
501	2009-01-01	S DAVID JACKSON
501	2009-01-01	LISA THALLER	JIM OLSON	2011-03-01
501	2009-01-01	MIKE HAMMER
501	2009-01-01	MIKE HAMMER
501	2009-01-01	LISA THALLER	JIM OLSON	2011-03-02

Plan Statistics for LES OLSON COMPANY PLAN

401k plan membership statisitcs for LES OLSON COMPANY PLAN

Measure Date Value
2022: LES OLSON COMPANY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 526
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 513
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 513
2021: LES OLSON COMPANY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 526
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 526
2020: LES OLSON COMPANY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 185
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 185
2019: LES OLSON COMPANY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 191
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 191
2018: LES OLSON COMPANY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 182
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 182
2017: LES OLSON COMPANY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 168
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 168
2016: LES OLSON COMPANY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 171
Number of retired or separated participants receiving benefits 2016-01-01 2
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 173
2015: LES OLSON COMPANY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 179
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 179
2014: LES OLSON COMPANY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 174
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 174
2013: LES OLSON COMPANY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 146
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 146
2012: LES OLSON COMPANY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 147
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 147
2011: LES OLSON COMPANY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 182
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 182
2009: LES OLSON COMPANY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 179
Number of retired or separated participants receiving benefits 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0
Number of participants with account balances 2009-01-01 0

Measure	Date	Value
2022: LES OLSON COMPANY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	526
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	513
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	513
2021: LES OLSON COMPANY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	526
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	526
2020: LES OLSON COMPANY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	185
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	185
2019: LES OLSON COMPANY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	191
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	191
2018: LES OLSON COMPANY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	182
Number of retired or separated participants receiving benefits	2018-01-01	0
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	182
2017: LES OLSON COMPANY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	168
Number of retired or separated participants receiving benefits	2017-01-01	0
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	168
2016: LES OLSON COMPANY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	171
Number of retired or separated participants receiving benefits	2016-01-01	2
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	173
2015: LES OLSON COMPANY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	179
Number of retired or separated participants receiving benefits	2015-01-01	0
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	179
2014: LES OLSON COMPANY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	174
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	174
2013: LES OLSON COMPANY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	146
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	146
2012: LES OLSON COMPANY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	147
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	147
2011: LES OLSON COMPANY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	182
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	182
2009: LES OLSON COMPANY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	179
Number of retired or separated participants receiving benefits	2009-01-01	2
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0
Number of participants with account balances	2009-01-01	0

Form 5500 Responses for LES OLSON COMPANY PLAN

2022: LES OLSON COMPANY 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: LES OLSON COMPANY 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: LES OLSON COMPANY 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 funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: LES OLSON COMPANY 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 funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: LES OLSON COMPANY 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 funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: LES OLSON COMPANY PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: LES OLSON COMPANY PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LES OLSON COMPANY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LES OLSON COMPANY PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: LES OLSON COMPANY PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: LES OLSON COMPANY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: LES OLSON COMPANY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: LES OLSON COMPANY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	22
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,921
Total amount of fees paid to insurance company	USD $575
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,921
Amount paid for insurance broker fees	575
Insurance broker organization code?	3

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	513
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,606
Total amount of fees paid to insurance company	USD $19,303
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,933,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,606
Amount paid for insurance broker fees	19303
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	297
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,162
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $206,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,162
Insurance broker organization code?	3

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

GRP00006112

Policy instance

Insurance contract or identification number	GRP00006112
Number of Individuals Covered	318
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $11,562
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	V LIFE
Welfare Benefit Premiums Paid to Carrier	USD $67,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,562
Additional information about fees paid to insurance broker	BONUS

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	98
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,234
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,234

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	165
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,493
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,493

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	319
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $13,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $72
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )

Policy contract number

1200000558

Policy instance

Insurance contract or identification number	1200000558
Number of Individuals Covered	152
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,530
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,530

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	526
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $33,985
Total amount of fees paid to insurance company	USD $16,992
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,703,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,985
Amount paid for insurance broker fees	16992
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	23
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,909
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $199,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,909
Insurance broker organization code?	3

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	22
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,018
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,018
Insurance broker organization code?	3

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	98
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,208
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,208

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	156
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,318
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,318

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	4
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $109
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $77

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )

Policy contract number

1200000558

Policy instance

Insurance contract or identification number	1200000558
Number of Individuals Covered	177
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,429
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,429

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

GRP00006112

Policy instance

Insurance contract or identification number	GRP00006112
Number of Individuals Covered	290
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,844
Total amount of fees paid to insurance company	USD $1,889
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	V LIFE
Welfare Benefit Premiums Paid to Carrier	USD $63,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,844
Amount paid for insurance broker fees	1889
Additional information about fees paid to insurance broker	BONUS

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	300
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $12,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	544
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $33,117
Total amount of fees paid to insurance company	USD $16,558
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,808,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,117
Amount paid for insurance broker fees	16558
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,395
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $200,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,395
Insurance broker organization code?	3

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,082
Total amount of fees paid to insurance company	USD $964
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,082
Amount paid for insurance broker fees	964
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )

Policy contract number

1200000558

Policy instance

Insurance contract or identification number	1200000558
Number of Individuals Covered	152
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,692
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,692

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	74
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,780
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,780

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100017783

Policy instance

Insurance contract or identification number	40000100017783
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,179
Total amount of fees paid to insurance company	USD $1,118
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,179
Amount paid for insurance broker fees	1118
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	139
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,232
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,232

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	270
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $9,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $123
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	266
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,261
Total amount of fees paid to insurance company	USD $898
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,261
Amount paid for insurance broker fees	898
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	5
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $132
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,267
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

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	275
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $9,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	147
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,657
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,657

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100017783

Policy instance

Insurance contract or identification number	40000100017783
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,790
Total amount of fees paid to insurance company	USD $1,086
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,790
Amount paid for insurance broker fees	1086
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	73
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,465
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,465

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	271
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,292
Total amount of fees paid to insurance company	USD $869
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,292
Amount paid for insurance broker fees	869
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	26
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,077
Total amount of fees paid to insurance company	USD $851
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,077
Amount paid for insurance broker fees	851
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )

Policy contract number

1200000558

Policy instance

Insurance contract or identification number	1200000558
Number of Individuals Covered	125
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $19,494
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,494

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	571
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $35,949
Total amount of fees paid to insurance company	USD $17,974
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,801,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,949
Amount paid for insurance broker fees	17974
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,059
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,059
Insurance broker organization code?	3

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	20
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,428
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $175,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,428
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	5
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $121
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

92063

Policy instance

Insurance contract or identification number	92063
Number of Individuals Covered	20
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,884
Welfare Benefit Premiums Paid to Carrier	USD $13,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,884
Insurance broker organization code?	3

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	261
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $9,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	133
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,175
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,175

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

18286

Policy instance

Insurance contract or identification number	18286
Number of Individuals Covered	46
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,235
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,235

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100017783

Policy instance

Insurance contract or identification number	40000100017783
Number of Individuals Covered	50
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,595
Total amount of fees paid to insurance company	USD $2,570
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,595
Amount paid for insurance broker fees	2570
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	60
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,391
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,391

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	1173
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $33,064
Total amount of fees paid to insurance company	USD $16,532
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,657,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,064
Amount paid for insurance broker fees	16532
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	260
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,230
Total amount of fees paid to insurance company	USD $1,658
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,230
Amount paid for insurance broker fees	1658
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	24
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $210
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $210
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

92063

Policy instance

Insurance contract or identification number	92063
Number of Individuals Covered	23
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,229
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,229
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INC

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	475
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $31,389
Total amount of fees paid to insurance company	USD $12,405
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,573,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,389
Amount paid for insurance broker fees	12405
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	15
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,277
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $168,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,277
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN INSURANCE OF NEVADA

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

Policy contract number

00520126

Policy instance

Insurance contract or identification number	00520126
Number of Individuals Covered	17
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,378
Total amount of fees paid to insurance company	USD $591
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,378
Amount paid for insurance broker fees	591
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN INSURANCE OF NEVADA

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	246
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,849
Total amount of fees paid to insurance company	USD $750
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,849
Amount paid for insurance broker fees	750
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS. AGENCY

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	54
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,246
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,246
Insurance broker name	GBS BENEFITS, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100017783

Policy instance

Insurance contract or identification number	40000100017783
Number of Individuals Covered	53
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,283
Total amount of fees paid to insurance company	USD $1,226
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,283
Amount paid for insurance broker fees	1226
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS AGENCY

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

18286

Policy instance

Insurance contract or identification number	18286
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,678
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,678
Insurance broker name	GBS BENEFITS, INC.

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	127
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,319
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,319
Insurance broker name	GBS BENEFITS, INC.

BLOMQUIST HALE CONSULTING INC (National Association of Insurance Commissioners NAIC id number: 10310 )

Policy contract number

Policy instance

Number of Individuals Covered	247
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $8,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $720
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $720
Insurance broker name	GBS BENEFITS, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $9,092
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,092
Insurance broker organization code?	3
Insurance broker name	KREEFT & LEGROW

LIBERTY DENTAL PLAN (National Association of Insurance Commissioners NAIC id number: 13566 )

Policy contract number

N10074

Policy instance

Insurance contract or identification number	N10074
Number of Individuals Covered	40
Insurance policy start date	2015-01-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $873
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $873
Insurance broker organization code?	3
Insurance broker name	WAYMARK INSURANCE SERVICES

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

18286

Policy instance

Insurance contract or identification number	18286
Number of Individuals Covered	18
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,200
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,200
Insurance broker name	GBS BENEFITS, INC.

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

12007310

Policy instance

Insurance contract or identification number	12007310
Number of Individuals Covered	120
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,231
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,231
Insurance broker name	GBS BENEFITS, INC.

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	492
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $24,057
Total amount of fees paid to insurance company	USD $10,933
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,207,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,057
Amount paid for insurance broker fees	10933
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	221
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,532
Total amount of fees paid to insurance company	USD $595
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,532
Amount paid for insurance broker fees	595
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS. AGENCY

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100017783

Policy instance

Insurance contract or identification number	40000100017783
Number of Individuals Covered	54
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,711
Total amount of fees paid to insurance company	USD $1,288
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,711
Amount paid for insurance broker fees	1288
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS AGENCY

OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 )

Policy contract number

Policy instance

Number of Individuals Covered	33
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $640
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $640
Insurance broker name	GBS BENEFITS, INC.

LIBERTY DENTAL PLAN (National Association of Insurance Commissioners NAIC id number: 13566 )

Policy contract number

N10074

Policy instance

Insurance contract or identification number	N10074
Number of Individuals Covered	39
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $928
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $928
Insurance broker organization code?	3
Insurance broker name	WAYMARK INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,592
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,592
Insurance broker organization code?	3
Insurance broker name	KREEFT & LEGROW

EDUCATORS MUTUAL PLANS LIFE, ACCIDENT AND HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 12515 )

Policy contract number

2525

Policy instance

Insurance contract or identification number	2525
Number of Individuals Covered	102
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,146
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,146
Insurance broker name	GORDON BROWN/ GBS BENEFITS

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	460
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $22,339
Total amount of fees paid to insurance company	USD $6,333
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,121,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,339
Amount paid for insurance broker fees	6333
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	9
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $768
Total amount of fees paid to insurance company	USD $145
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $182
Amount paid for insurance broker fees	21
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	TOM GILLIGAN

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010184602

Policy instance

Insurance contract or identification number	000010184602
Number of Individuals Covered	212
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,468
Total amount of fees paid to insurance company	USD $668
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,468
Amount paid for insurance broker fees	668
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS. AGENCY

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	440
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $20,016
Total amount of fees paid to insurance company	USD $3,403
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,005,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,016
Amount paid for insurance broker fees	3403
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS

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

Policy contract number

221237G

Policy instance

Insurance contract or identification number	221237G
Number of Individuals Covered	205
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,330
Total amount of fees paid to insurance company	USD $332
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-4
Insurance broker organization code?	3
Amount paid for insurance broker fees	332
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	LEAVITT BENEFIT SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	12
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,092
Total amount of fees paid to insurance company	USD $266
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,152
Amount paid for insurance broker fees	146
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	TOM GILLIGAN

EDUCATORS MUTUAL PLANS LIFE, ACCIDENT AND HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 12515 )

Policy contract number

2525

Policy instance

Insurance contract or identification number	2525
Number of Individuals Covered	97
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,956
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,956
Insurance broker organization code?	3
Insurance broker name	GORDON BROWN/ GBS BENEFITS

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	16
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,206
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,206
Insurance broker organization code?	3
Insurance broker name	KREEFT & LEGROW

LIBERTY DENTAL PLAN (National Association of Insurance Commissioners NAIC id number: 13566 )

Policy contract number

N10074

Policy instance

Insurance contract or identification number	N10074
Number of Individuals Covered	41
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $787
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $787
Insurance broker organization code?	3
Insurance broker name	WAYMARK INSURANCE SERVICES

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	433
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $29,945
Total amount of fees paid to insurance company	USD $8,435
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $902,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,300
Amount paid for insurance broker fees	7582
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS

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

Policy contract number

221237G

Policy instance

Insurance contract or identification number	221237G
Number of Individuals Covered	189
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,112
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,301
Insurance broker organization code?	3
Insurance broker name	GBS BENEFITS INS AGENCY

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	15
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,304
Total amount of fees paid to insurance company	USD $25
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $671
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	TOM GILLIGAN

EDUCATORS MUTUAL PLANS LIFE, ACCIDENT AND HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 12515 )

Policy contract number

2525

Policy instance

Insurance contract or identification number	2525
Number of Individuals Covered	87
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,174
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,142
Insurance broker organization code?	3
Insurance broker name	GORDON BROWN/ GBS BENEFITS

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	15
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,688
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,688
Insurance broker organization code?	3
Insurance broker name	KREEFT & LEGROW

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-016136-2887

Policy instance

Insurance contract or identification number	010-016136-2887
Number of Individuals Covered	14
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $858
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $858
Insurance broker organization code?	3
Insurance broker name	KREEFT & LEGROW

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-016136-2887

Policy instance

Insurance contract or identification number	010-016136-2887
Number of Individuals Covered	26
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,935
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	430
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $26,109
Total amount of fees paid to insurance company	USD $9,006
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $806,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

473247

Policy instance

Insurance contract or identification number	473247
Number of Individuals Covered	16
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,555
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $106,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EDUCATORS MUTUAL PLANS LIFE, ACCIDENT AND HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 12515 )

Policy contract number

2525

Policy instance

Insurance contract or identification number	2525
Number of Individuals Covered	85
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,105
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	14
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,712
Total amount of fees paid to insurance company	USD $64
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,562
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

221237G

Policy instance

Insurance contract or identification number	221237G
Number of Individuals Covered	183
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,573
Total amount of fees paid to insurance company	USD $550
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

V19305

Policy instance

Insurance contract or identification number	V19305
Number of Individuals Covered	16
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $514
Welfare Benefit Premiums Paid to Carrier	USD $101,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SELECTHEALTH (National Association of Insurance Commissioners NAIC id number: 95153 )

Policy contract number

G1006572 1001

Policy instance

Insurance contract or identification number	G1006572 1001
Number of Individuals Covered	447
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $32,287
Total amount of fees paid to insurance company	USD $12,045
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,090,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EDUCATORS MUTUAL PLANS LIFE, ACCIDENT AND HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 12515 )

Policy contract number

2525

Policy instance

Insurance contract or identification number	2525
Number of Individuals Covered	100
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,307
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7297401

Policy instance

Insurance contract or identification number	E7297401
Number of Individuals Covered	18
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,645
Total amount of fees paid to insurance company	USD $74
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,165
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

221237G

Policy instance

Insurance contract or identification number	221237G
Number of Individuals Covered	167
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,147
Total amount of fees paid to insurance company	USD $445
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	LES OLSON COMPANY, INC.
Employer identification number (EIN):	870324153
NAIC Classification:	453210
NAIC Description:	Office Supplies and Stationery Stores