401k Plan data: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT plan

LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 401k Plan overview

Plan Name	LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT
Plan identification number	501

LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT Benefits

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

401k Sponsoring company profile

LIFELINE MEDICAL ASSOCIATES, LLC has sponsored the creation of one or more 401k plans.

Company Name: LIFELINE MEDICAL ASSOCIATES, LLC

Employer identification number (EIN): 943283324

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Additional information about LIFELINE MEDICAL ASSOCIATES, LLC

Jurisdiction of Incorporation: New Jersey Division of Revenue and Enterprise Services

Incorporation Date:

Company Identification Number: 0600041862

More information about LIFELINE MEDICAL ASSOCIATES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01 KAREN RYER 2024-01-31
501 2021-06-01 REBECCA SANANDAJIAN 2022-12-27
501 2020-06-01
501 2019-06-01
501 2018-06-01
501 2017-06-01 CRAIG BISSINGER CRAIG BISSINGER 2018-10-01
501 2016-06-01 CRAIG BISSINGER CRAIG BISSINGER 2017-12-20
501 2015-06-01 CRAIG BISSINGER CRAIG BISSINGER 2016-10-24
501 2014-06-01 CRAIG BISSINGER CRAIG BISSINGER 2015-11-20
501 2013-06-01 CRAIG BISSINGER CRAIG BISSINGER 2014-12-04
501 2012-06-01 WALTER FRIEDEL WALTER FRIEDEL 2013-10-10
501 2011-06-01 WALTER FRIEDEL WALTER FRIEDEL 2012-12-26
501 2009-06-01 WALTER FRIEDEL WALTER FRIEDEL 2010-12-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-06-01	KAREN RYER	2024-01-31
501	2021-06-01	REBECCA SANANDAJIAN	2022-12-27
501	2020-06-01
501	2019-06-01
501	2018-06-01
501	2017-06-01	CRAIG BISSINGER		CRAIG BISSINGER	2018-10-01
501	2016-06-01	CRAIG BISSINGER		CRAIG BISSINGER	2017-12-20
501	2015-06-01	CRAIG BISSINGER		CRAIG BISSINGER	2016-10-24
501	2014-06-01	CRAIG BISSINGER		CRAIG BISSINGER	2015-11-20
501	2013-06-01	CRAIG BISSINGER		CRAIG BISSINGER	2014-12-04
501	2012-06-01	WALTER FRIEDEL		WALTER FRIEDEL	2013-10-10
501	2011-06-01	WALTER FRIEDEL		WALTER FRIEDEL	2012-12-26
501	2009-06-01	WALTER FRIEDEL		WALTER FRIEDEL	2010-12-02

Plan Statistics for LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT

401k plan membership statisitcs for LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT

Measure Date Value
2022: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2022 401k membership
Total participants, beginning-of-year 2022-06-01 518
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 498
Number of retired or separated participants receiving benefits 2022-06-01 2
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 500
2021: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2021 401k membership
Total participants, beginning-of-year 2021-06-01 519
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 512
Number of retired or separated participants receiving benefits 2021-06-01 6
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 518
2020: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2020 401k membership
Total participants, beginning-of-year 2020-06-01 457
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 519
Total of all active and inactive participants 2020-06-01 519
2019: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2019 401k membership
Total participants, beginning-of-year 2019-06-01 508
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 457
Total of all active and inactive participants 2019-06-01 457
2018: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2018 401k membership
Total participants, beginning-of-year 2018-06-01 459
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 508
Total of all active and inactive participants 2018-06-01 508
2017: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2017 401k membership
Total participants, beginning-of-year 2017-06-01 404
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 459
Total of all active and inactive participants 2017-06-01 459
2016: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2016 401k membership
Total participants, beginning-of-year 2016-06-01 451
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 404
Total of all active and inactive participants 2016-06-01 404
2015: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2015 401k membership
Total participants, beginning-of-year 2015-06-01 498
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 451
Total of all active and inactive participants 2015-06-01 451
2014: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2014 401k membership
Total participants, beginning-of-year 2014-06-01 211
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 498
Total of all active and inactive participants 2014-06-01 498
2013: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2013 401k membership
Total participants, beginning-of-year 2013-06-01 210
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 211
Total of all active and inactive participants 2013-06-01 211
2012: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2012 401k membership
Total participants, beginning-of-year 2012-06-01 189
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 210
Total of all active and inactive participants 2012-06-01 210
2011: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2011 401k membership
Total participants, beginning-of-year 2011-06-01 204
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 189
Total of all active and inactive participants 2011-06-01 189
2009: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2009 401k membership
Total participants, beginning-of-year 2009-06-01 200
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 203
Total of all active and inactive participants 2009-06-01 203

Measure	Date	Value
2022: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2022 401k membership
Total participants, beginning-of-year	2022-06-01	518
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	498
Number of retired or separated participants receiving benefits	2022-06-01	2
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	500
2021: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2021 401k membership
Total participants, beginning-of-year	2021-06-01	519
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	512
Number of retired or separated participants receiving benefits	2021-06-01	6
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	518
2020: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2020 401k membership
Total participants, beginning-of-year	2020-06-01	457
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	519
Total of all active and inactive participants	2020-06-01	519
2019: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2019 401k membership
Total participants, beginning-of-year	2019-06-01	508
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	457
Total of all active and inactive participants	2019-06-01	457
2018: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2018 401k membership
Total participants, beginning-of-year	2018-06-01	459
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	508
Total of all active and inactive participants	2018-06-01	508
2017: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2017 401k membership
Total participants, beginning-of-year	2017-06-01	404
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	459
Total of all active and inactive participants	2017-06-01	459
2016: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2016 401k membership
Total participants, beginning-of-year	2016-06-01	451
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	404
Total of all active and inactive participants	2016-06-01	404
2015: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2015 401k membership
Total participants, beginning-of-year	2015-06-01	498
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	451
Total of all active and inactive participants	2015-06-01	451
2014: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2014 401k membership
Total participants, beginning-of-year	2014-06-01	211
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	498
Total of all active and inactive participants	2014-06-01	498
2013: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2013 401k membership
Total participants, beginning-of-year	2013-06-01	210
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	211
Total of all active and inactive participants	2013-06-01	211
2012: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2012 401k membership
Total participants, beginning-of-year	2012-06-01	189
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	210
Total of all active and inactive participants	2012-06-01	210
2011: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2011 401k membership
Total participants, beginning-of-year	2011-06-01	204
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	189
Total of all active and inactive participants	2011-06-01	189
2009: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2009 401k membership
Total participants, beginning-of-year	2009-06-01	200
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	203
Total of all active and inactive participants	2009-06-01	203

Form 5500 Responses for LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT

2022: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: LIFELINE MEDICAL ASSOCIATES, LLC FLEXIBLE BENEFIT 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	This submission is the final filing	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

630690

Policy instance

Insurance contract or identification number	630690
Number of Individuals Covered	130
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1,546
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,546
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	295
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $96,653
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $4,179,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96,653
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	296
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $6,115
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $265,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,115
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	47
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $369
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $369
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	241
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $6,249
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $197,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,249
Insurance broker organization code?	3

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	600
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $3,926
Total amount of fees paid to insurance company	USD $410
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,926
Amount paid for insurance broker fees	410
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

LIFE-0000195034

Policy instance

Insurance contract or identification number	LIFE-0000195034
Number of Individuals Covered	498
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $522
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $522
Insurance broker organization code?	3

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

Policy contract number

STD-0000195033

Policy instance

Insurance contract or identification number	STD-0000195033
Number of Individuals Covered	21
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $783
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $783
Insurance broker organization code?	3

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

Policy contract number

ACC-0000000330

Policy instance

Insurance contract or identification number	ACC-0000000330
Number of Individuals Covered	108
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $3,153
Total amount of fees paid to insurance company	USD $788
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,153
Insurance broker organization code?	3
Amount paid for insurance broker fees	788
Additional information about fees paid to insurance broker	CONSULTING FEES, ENROLLMENT SERVICES

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

Policy contract number

CI-0000000331

Policy instance

Insurance contract or identification number	CI-0000000331
Number of Individuals Covered	56
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $670
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $670
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

8210010

Policy instance

Insurance contract or identification number	8210010
Number of Individuals Covered	63
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
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 $13,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0630690

Policy instance

Insurance contract or identification number	0630690
Number of Individuals Covered	40
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $24,690
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $493,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24690
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEE
Insurance broker organization code?	3

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

Policy contract number

LIFE-0000195035

Policy instance

Insurance contract or identification number	LIFE-0000195035
Number of Individuals Covered	205
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $14,149
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $94,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,149
Insurance broker organization code?	3

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	574
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $3,641
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $36,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,481
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	219
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $6,107
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $198,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,825
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	40
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $403
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $318
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	278
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $7,080
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $294,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,817
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	278
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $84,964
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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 $3,527,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,748
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK968875

Policy instance

Insurance contract or identification number	OK968875
Number of Individuals Covered	512
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $2,415
Total amount of fees paid to insurance company	USD $1,579
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,493
Insurance broker organization code?	3
Amount paid for insurance broker fees	1579
Additional information about fees paid to insurance broker	GENERAL AGENCY FEES

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967357

Policy instance

Insurance contract or identification number	FLX967357
Number of Individuals Covered	512
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $3,192
Total amount of fees paid to insurance company	USD $4,229
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $94,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4229
Additional information about fees paid to insurance broker	GENERAL AGENCY FEES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $3,192

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT963088

Policy instance

Insurance contract or identification number	VDT963088
Number of Individuals Covered	20
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,697
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,697
Insurance broker organization code?	3

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

Policy contract number

ACC-0000000330

Policy instance

Insurance contract or identification number	ACC-0000000330
Number of Individuals Covered	101
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $2,207
Total amount of fees paid to insurance company	USD $552
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,731
Insurance broker organization code?	3
Amount paid for insurance broker fees	552
Additional information about fees paid to insurance broker	CONSULTING FEES, ENROLLMENT SERVICES

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

Policy contract number

CI-0000000331

Policy instance

Insurance contract or identification number	CI-0000000331
Number of Individuals Covered	57
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $892
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $691
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

8210010

Policy instance

Insurance contract or identification number	8210010
Number of Individuals Covered	54
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LEGAL
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 $13,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0630690

Policy instance

Insurance contract or identification number	0630690
Number of Individuals Covered	48
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	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 $35,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967357

Policy instance

Insurance contract or identification number	FLX967357
Number of Individuals Covered	164
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,255
Total amount of fees paid to insurance company	USD $2,152
Life Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2152
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,255

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 968875

Policy instance

Insurance contract or identification number	OK 968875
Number of Individuals Covered	519
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $980
Total amount of fees paid to insurance company	USD $414
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $980
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES & SERVICE

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	280
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $104,334
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,606,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,334
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	280
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $9,806
Total amount of fees paid to insurance company	USD $0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $363,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,806
Insurance broker organization code?	3

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	273
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $3,793
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,793
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	55
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $479
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $479
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	245
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $7,317
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $249,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,317
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00630690

Policy instance

Insurance contract or identification number	00630690
Number of Individuals Covered	68
Insurance policy start date	2020-10-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $20,497
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $409,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	20497
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT963088

Policy instance

Insurance contract or identification number	VDT963088
Insurance policy start date	2020-10-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,138
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,138
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

8210010

Policy instance

Insurance contract or identification number	8210010
Number of Individuals Covered	47
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $12,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ACC-0000000330

Policy instance

Insurance contract or identification number	ACC-0000000330
Number of Individuals Covered	114
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $3,357
Total amount of fees paid to insurance company	USD $839
Temporary Disability Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,357
Insurance broker organization code?	3
Amount paid for insurance broker fees	839
Additional information about fees paid to insurance broker	CONSULTING FEES, ENROLLMENT SERVICES

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

Policy contract number

CI-0000000331

Policy instance

Insurance contract or identification number	CI-0000000331
Number of Individuals Covered	68
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $2,014
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,014

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	277
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $101,353
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,486,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $101,353
Insurance broker organization code?	3

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	457
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $3,221
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,221
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	289
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $12,425
Total amount of fees paid to insurance company	USD $0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $460,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,425
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 968875

Policy instance

Insurance contract or identification number	OK 968875
Number of Individuals Covered	448
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $184
Total amount of fees paid to insurance company	USD $77
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $184
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES & SERVICE

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	195
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $6,475
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,475
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	59
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $592
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $592
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967357

Policy instance

Insurance contract or identification number	FLX967357
Number of Individuals Covered	136
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $3,729
Total amount of fees paid to insurance company	USD $3,645
Life Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,729
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES & SERVICE

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	301
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $97,842
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,200,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $97,842
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 968875

Policy instance

Insurance contract or identification number	OK 968875
Number of Individuals Covered	474
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $205
Total amount of fees paid to insurance company	USD $85
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $205
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES & SERVICE

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	508
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $3,754
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,754
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	77
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $14,734
Total amount of fees paid to insurance company	USD $0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $513,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,734
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3339850

Policy instance

Insurance contract or identification number	3339850
Number of Individuals Covered	276
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $9,340
Total amount of fees paid to insurance company	USD $9,112
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $229,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,340
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967357

Policy instance

Insurance contract or identification number	FLX967357
Number of Individuals Covered	214
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $3,700
Total amount of fees paid to insurance company	USD $3,500
Life Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,700
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES & SERVICE

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

Policy contract number

010-043341

Policy instance

Insurance contract or identification number	010-043341
Number of Individuals Covered	459
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,319
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,319
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CHRISTINE S ANDREWS

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	88
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $18,134
Total amount of fees paid to insurance company	USD $0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $561,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,134
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CHRISTINE S ANDREWS

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3339850

Policy instance

Insurance contract or identification number	3339850
Number of Individuals Covered	257
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $8,751
Total amount of fees paid to insurance company	USD $8,538
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $214,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,751
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE/GENERAL AGENT PAYMENTS
Insurance broker name	ROGERS BENEFIT GROUP INC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8502F

Policy instance

Insurance contract or identification number	8502F
Number of Individuals Covered	272
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $89,124
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,608,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89,124
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CHRISTINE S ANDREWS

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK 968875

Policy instance

Insurance contract or identification number	OK 968875
Number of Individuals Covered	455
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $166
Total amount of fees paid to insurance company	USD $108
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $166
Amount paid for insurance broker fees	39
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3
Insurance broker name	ROGERS BENEFIT GROUP INC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967357

Policy instance

Insurance contract or identification number	FLX967357
Number of Individuals Covered	143
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,582
Total amount of fees paid to insurance company	USD $4,585
Life Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,582
Amount paid for insurance broker fees	1677
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3
Insurance broker name	ROGERS BENEFIT GROUP INC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0473450

Policy instance

Insurance contract or identification number	0473450
Number of Individuals Covered	451
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $78,073
Total amount of fees paid to insurance company	USD $8,159
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,549,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,331
Amount paid for insurance broker fees	8159
Additional information about fees paid to insurance broker	2015 SG PERSISTENCY ACHIEVEMENT OVERRIDE
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0473450

Policy instance

Insurance contract or identification number	0473450
Number of Individuals Covered	498
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $140,087
Total amount of fees paid to insurance company	USD $1,452
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,171,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,438
Amount paid for insurance broker fees	1379
Additional information about fees paid to insurance broker	PM CROSS-SALE
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	211
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $67,887
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,275,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,269
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	211
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $11,775
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $392,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,897
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	183
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $5,033
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,372
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0473450

Policy instance

Insurance contract or identification number	0473450
Number of Individuals Covered	312
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $44
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, LIFE
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROGERS BENEFIT GROUP INC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	210
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $72,218
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,293,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,218
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	210
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $14,082
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $382,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,082
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	179
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $5,025
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $135,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,025
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

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

Policy contract number

095895

Policy instance

Insurance contract or identification number	095895
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $992
Total amount of fees paid to insurance company	USD $74
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $992
Amount paid for insurance broker fees	74
Additional information about fees paid to insurance broker	ADDITIONAL COMENSATION
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

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

Policy contract number

095896

Policy instance

Insurance contract or identification number	095896
Number of Individuals Covered	87
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $4,335
Total amount of fees paid to insurance company	USD $217
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $26,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,335
Amount paid for insurance broker fees	217
Additional information about fees paid to insurance broker	ADDITIONAL COMENSATION
Insurance broker organization code?	3
Insurance broker name	OVATION BENEFITS GROUP LLC

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	167
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $5,119
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

095896

Policy instance

Insurance contract or identification number	095896
Number of Individuals Covered	83
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $3,415
Total amount of fees paid to insurance company	USD $171
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $22,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	189
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $72,947
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,317,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	189
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $14,213
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $386,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

095895

Policy instance

Insurance contract or identification number	095895
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $928
Total amount of fees paid to insurance company	USD $70
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	203
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $83,199
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,087,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	199
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $16,030
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Were dividends or retroactive rate refunds paid as a credit?	Yes
Welfare Benefit Premiums Paid to Carrier	USD $401,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

80068

Policy instance

Insurance contract or identification number	80068
Number of Individuals Covered	102
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $5,262
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

095895

Policy instance

Insurance contract or identification number	095895
Number of Individuals Covered	292
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,302
Total amount of fees paid to insurance company	USD $135
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

095896

Policy instance

Insurance contract or identification number	095896
Number of Individuals Covered	84
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,382
Total amount of fees paid to insurance company	USD $298
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $19,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	LIFELINE MEDICAL ASSOCIATES, LLC
Employer identification number (EIN):	943283324
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	New Jersey Division of Revenue and Enterprise Services
Incorporation Date:
Company Identification Number:	0600041862