401k Plan data: SKYLINE FINANCIAL CORP BENEFITS PLAN plan

SKYLINE FINANCIAL CORP BENEFITS PLAN 401k Plan overview

Plan Name	SKYLINE FINANCIAL CORP BENEFITS PLAN
Plan identification number	501

SKYLINE FINANCIAL CORP BENEFITS PLAN Benefits

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

401k Sponsoring company profile

SKYLINE FINANCIAL CORP BENEFITS PLAN has sponsored the creation of one or more 401k plans.

Company Name: SKYLINE FINANCIAL CORP BENEFITS PLAN

Employer identification number (EIN): 953990375

NAIC Classification: 531390
NAIC Description: Other Activities Related to Real Estate

Additional information about SKYLINE FINANCIAL CORP BENEFITS PLAN

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 3923316

More information about SKYLINE FINANCIAL CORP BENEFITS PLAN

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SKYLINE FINANCIAL CORP BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-06-01 PRATEEK KHOKHAR
501 2014-06-01 PRATEEK KHOKHAR
501 2013-06-01 BRYAN THOMPSON
501 2012-06-01 BRYAN THOMPSON
501 2011-06-01 BRIDGET GRAHAM
501 2011-01-01 BRIDGET GRAHAM

Plan id#	Filing Submission Date	Name of Administrator
501	2014-06-01	PRATEEK KHOKHAR
501	2014-06-01	PRATEEK KHOKHAR
501	2013-06-01	BRYAN THOMPSON
501	2012-06-01	BRYAN THOMPSON
501	2011-06-01	BRIDGET GRAHAM
501	2011-01-01	BRIDGET GRAHAM

Plan Statistics for SKYLINE FINANCIAL CORP BENEFITS PLAN

401k plan membership statisitcs for SKYLINE FINANCIAL CORP BENEFITS PLAN

Measure Date Value
2014: SKYLINE FINANCIAL CORP BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 384
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 466
Total of all active and inactive participants 2014-06-01 466
Total participants 2014-06-01 466
2013: SKYLINE FINANCIAL CORP BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 392
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 384
Total of all active and inactive participants 2013-06-01 384
Total participants 2013-06-01 384
2012: SKYLINE FINANCIAL CORP BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 284
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 392
Total of all active and inactive participants 2012-06-01 392
Total participants 2012-06-01 392
2011: SKYLINE FINANCIAL CORP BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 261
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 284
Total of all active and inactive participants 2011-06-01 284
Total participants 2011-06-01 284
Total participants, beginning-of-year 2011-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 284
Total of all active and inactive participants 2011-01-01 284
Total participants 2011-01-01 284

Measure	Date	Value
2014: SKYLINE FINANCIAL CORP BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	384
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	466
Total of all active and inactive participants	2014-06-01	466
Total participants	2014-06-01	466
2013: SKYLINE FINANCIAL CORP BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	392
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	384
Total of all active and inactive participants	2013-06-01	384
Total participants	2013-06-01	384
2012: SKYLINE FINANCIAL CORP BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	284
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	392
Total of all active and inactive participants	2012-06-01	392
Total participants	2012-06-01	392
2011: SKYLINE FINANCIAL CORP BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	261
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	284
Total of all active and inactive participants	2011-06-01	284
Total participants	2011-06-01	284
Total participants, beginning-of-year	2011-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	284
Total of all active and inactive participants	2011-01-01	284
Total participants	2011-01-01	284

Form 5500 Responses for SKYLINE FINANCIAL CORP BENEFITS PLAN

2014: SKYLINE FINANCIAL CORP BENEFITS PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Submission has been amended	Yes
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: SKYLINE FINANCIAL CORP BENEFITS PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Submission has been amended	No
2013-06-01	This submission is the final filing	No
2013-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-06-01	Plan is a collectively bargained plan	No
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: SKYLINE FINANCIAL CORP BENEFITS PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Submission has been amended	No
2012-06-01	This submission is the final filing	No
2012-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-06-01	Plan is a collectively bargained plan	No
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: SKYLINE FINANCIAL CORP BENEFITS PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Submission has been amended	Yes
2011-06-01	This submission is the final filing	No
2011-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-06-01	Plan is a collectively bargained plan	No
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

228780

Policy instance

Insurance contract or identification number	228780
Number of Individuals Covered	179
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $16,209
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $163,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,209
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	142
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $5,909
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE
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 $39,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,909
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GLUG0ALPB

Policy instance

Insurance contract or identification number	GLUG0ALPB
Number of Individuals Covered	448
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $2,282
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $15,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,282
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	466
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,989
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,989
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GUG0ALPB

Policy instance

Insurance contract or identification number	GUG0ALPB
Number of Individuals Covered	151
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $151
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $1,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $151
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GLTD0ALPB

Policy instance

Insurance contract or identification number	GLTD0ALPB
Number of Individuals Covered	6
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $559
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $559
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GUC0ALPB

Policy instance

Insurance contract or identification number	GUC0ALPB
Number of Individuals Covered	85
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $2,564
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SHORT TERM DISABILITY
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 $17,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,564
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GUPR0ALPB

Policy instance

Insurance contract or identification number	GUPR0ALPB
Number of Individuals Covered	87
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,764
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LONG TERM DISABILITY
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 $25,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,764
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0803881HNO

Policy instance

Insurance contract or identification number	0803881HNO
Number of Individuals Covered	257
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,040,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,442
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

0803881

Policy instance

Insurance contract or identification number	0803881
Number of Individuals Covered	258
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,416,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Total amount of commissions paid to insurance broker	USD $82,989
Commission paid to Insurance Broker	USD $82,989
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	6
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $477
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $477
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	7
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $154
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $1,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	68
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,172
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY STD
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 $14,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,172
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	123
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $890
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE
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 $39,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $890
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	325
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,596
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,596
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

228780

Policy instance

Insurance contract or identification number	228780
Number of Individuals Covered	139
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $15,191
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $150,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,191
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	340
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,263
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,263
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

902409

Policy instance

Insurance contract or identification number	902409
Number of Individuals Covered	160
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,662
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,662
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	71
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $3,144
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LTD
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 $20,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,144
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

744438

Policy instance

Insurance contract or identification number	744438
Number of Individuals Covered	384
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $119,947
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,162,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119,947
Insurance broker organization code?	3
Insurance broker name	PETER FOY & ASSOCIATES

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

Policy contract number

GUC0ALPB

Policy instance

Insurance contract or identification number	GUC0ALPB
Number of Individuals Covered	72
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,756
Total amount of fees paid to insurance company	USD $247
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,756
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )

Policy contract number

KM05992309

Policy instance

Insurance contract or identification number	KM05992309
Number of Individuals Covered	241
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,924
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,924
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES INS SVS

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

Policy contract number

KM05992309

Policy instance

Insurance contract or identification number	KM05992309
Number of Individuals Covered	392
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $12,396
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,396
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES INS SVS

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

Policy contract number

GUGOALPB

Policy instance

Insurance contract or identification number	GUGOALPB
Number of Individuals Covered	10
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $176
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $176
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

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

Policy contract number

GLUG0ALPB

Policy instance

Insurance contract or identification number	GLUG0ALPB
Number of Individuals Covered	349
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,483
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDNETAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,483
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

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

Policy contract number

GUPR0ALPB

Policy instance

Insurance contract or identification number	GUPR0ALPB
Number of Individuals Covered	63
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,197
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,197
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

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

Policy contract number

GLTD0ALPB

Policy instance

Insurance contract or identification number	GLTD0ALPB
Number of Individuals Covered	9
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $543
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $543
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

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

Policy contract number

G000ALPB

Policy instance

Insurance contract or identification number	G000ALPB
Number of Individuals Covered	127
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $5,330
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $35,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,330
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

AMERICAN SPECIALTY HEALTH (National Association of Insurance Commissioners NAIC id number: 84697 )

Policy contract number

14855-00

Policy instance

Insurance contract or identification number	14855-00
Number of Individuals Covered	212
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,101
Other welfare benefits provided	CHIROPRACTIC/ACUPUNCTURE
Welfare Benefit Premiums Paid to Carrier	USD $13,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,101
Insurance broker organization code?	3
Insurance broker name	PETER C. FOY & ASSOCIATES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	340
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,222
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,222
Insurance broker organization code?	3
Insurance broker name	PETER C FOY & ASSOCIATES

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

Policy contract number

0744438

Policy instance

Insurance contract or identification number	0744438
Number of Individuals Covered	371
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $117,940
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,866,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $117,940
Insurance broker organization code?	3
Insurance broker name	PETER C. FOY & ASSOCIATES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	56
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $4,935
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	68
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $876
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Life Insurance Welfare Benefit	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	244
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,393
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )

Policy contract number

ORLG107154

Policy instance

Insurance contract or identification number	ORLG107154
Number of Individuals Covered	38
Insurance policy start date	2011-06-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $1,467
Welfare Benefit Premiums Paid to Carrier	USD $32,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA BENEFITS DENTAL PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1533

Policy instance

Insurance contract or identification number	1533
Number of Individuals Covered	49
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,116
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	68
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $876
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	244
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,393
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275880

Policy instance

Insurance contract or identification number	275880
Number of Individuals Covered	284
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $56,459
Welfare Benefit Premiums Paid to Carrier	USD $1,012,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	225
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $3,616
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Long Term Disability Insurance Welfare Benefit	Yes

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	104
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $9,433
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA BENEFITS DENTAL PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1533

Policy instance

Insurance contract or identification number	1533
Number of Individuals Covered	49
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,116
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )

Policy contract number

ORLG107154

Policy instance

Insurance contract or identification number	ORLG107154
Number of Individuals Covered	38
Insurance policy start date	2011-06-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $1,467
Welfare Benefit Premiums Paid to Carrier	USD $32,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275880

Policy instance

Insurance contract or identification number	275880
Number of Individuals Covered	284
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $56,459
Welfare Benefit Premiums Paid to Carrier	USD $1,012,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

218390

Policy instance

Insurance contract or identification number	218390
Number of Individuals Covered	104
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $9,433
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275880

Policy instance

Insurance contract or identification number	275880
Number of Individuals Covered	261
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $48,740
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $953,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )

Policy contract number

ORLG 107154

Policy instance

Insurance contract or identification number	ORLG 107154
Number of Individuals Covered	34
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $4,762
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $168,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

12484

Policy instance

Insurance contract or identification number	12484
Number of Individuals Covered	105
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $8,571
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

867339G

Policy instance

Insurance contract or identification number	867339G
Number of Individuals Covered	51
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $4,287
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $28,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9789009

Policy instance

Insurance contract or identification number	9789009
Number of Individuals Covered	173
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,003
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SKYLINE FINANCIAL CORP BENEFITS PLAN
Employer identification number (EIN):	953990375
NAIC Classification:	531390
NAIC Description:	Other Activities Related to Real Estate

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	3923316