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SEBESTA, INC. CAFETERIA PLAN 401k Plan overview

Plan NameSEBESTA, INC. CAFETERIA PLAN
Plan identification number 501

SEBESTA, INC. CAFETERIA PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    SEBESTA, INC. has sponsored the creation of one or more 401k plans.

    Company Name:SEBESTA, INC.
    Employer identification number (EIN):411787792
    NAIC Classification:541330
    NAIC Description:Engineering Services

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan SEBESTA, INC. CAFETERIA PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5012016-01-01MARYAM PETERS
    5012015-01-01MARYAM ARMAJANI-PETERS MARYAM ARMAJANI-PETERS2016-06-08
    5012014-01-01MARYAM ARMAJANI-PETERS MARYAM ARMAJANI-PETERS2015-06-26
    5012013-01-01MARYAM ARMAJANI-PETERS MARYAM ARMAJANI-PETERS2014-07-28
    5012012-01-01MARYAM ARMAJANI-PETERS
    5012011-01-01MARYAM ARMAJANI-PETERS
    5012009-01-01BRENDA PODRATZ
    5012009-01-01MARYAM ARMAJANI-PETERS
    5012008-01-01MARYAM ARMAJANI-PETERS
    5012007-01-01MARYAM ARMAJANI-PETERS
    5012006-01-01MARYAM ARMAJANI-PETERS

    Plan Statistics for SEBESTA, INC. CAFETERIA PLAN

    401k plan membership statisitcs for SEBESTA, INC. CAFETERIA PLAN

    Measure Date Value
    2016
    Total participants, beginning-of-year2016-01-01166
    Total number of active participants reported on line 7a of the Form 55002016-01-010
    Number of retired or separated participants receiving benefits2016-01-010
    Number of other retired or separated participants entitled to future benefits2016-01-010
    Total of all active and inactive participants2016-01-010
    2015
    Total participants, beginning-of-year2015-01-01175
    Total number of active participants reported on line 7a of the Form 55002015-01-01166
    Total of all active and inactive participants2015-01-01166
    2014
    Total participants, beginning-of-year2014-01-01231
    Total number of active participants reported on line 7a of the Form 55002014-01-01175
    Total of all active and inactive participants2014-01-01175
    2013
    Total participants, beginning-of-year2013-01-01214
    Total number of active participants reported on line 7a of the Form 55002013-01-01214
    Total of all active and inactive participants2013-01-01214
    2012
    Total participants, beginning-of-year2012-01-01187
    Total number of active participants reported on line 7a of the Form 55002012-01-01214
    Total of all active and inactive participants2012-01-01214
    2011
    Total participants, beginning-of-year2011-01-01180
    Total number of active participants reported on line 7a of the Form 55002011-01-01187
    Number of retired or separated participants receiving benefits2011-01-010
    Number of other retired or separated participants entitled to future benefits2011-01-010
    Total of all active and inactive participants2011-01-01187
    2009
    Total participants, beginning-of-year2009-01-01398
    Total number of active participants reported on line 7a of the Form 55002009-01-01362
    Number of retired or separated participants receiving benefits2009-01-010
    Number of other retired or separated participants entitled to future benefits2009-01-010
    Total of all active and inactive participants2009-01-01362
    2008
    Total participants, beginning-of-year2008-01-01192
    Total number of active participants reported on line 7a of the Form 55002008-01-01398
    Total of all active and inactive participants2008-01-01398
    2007
    Total participants, beginning-of-year2007-01-01362
    Total number of active participants reported on line 7a of the Form 55002007-01-01192
    Total of all active and inactive participants2007-01-01192
    2006
    Total participants, beginning-of-year2006-01-01396
    Total number of active participants reported on line 7a of the Form 55002006-01-01362
    Total of all active and inactive participants2006-01-01362

    Form 5500 Responses

    2016
    2016-01-01Type of plan entitySingle employer plan
    2016-01-01Submission has been amendedNo
    2016-01-01This submission is the final filingYes
    2016-01-01This return/report is a short plan year return/report (less than 12 months)No
    2016-01-01Plan is a collectively bargained planNo
    2016-01-01Plan funding arrangement – InsuranceYes
    2016-01-01Plan funding arrangement – General assets of the sponsorYes
    2016-01-01Plan benefit arrangement – InsuranceYes
    2016-01-01Plan benefit arrangement – General assets of the sponsorYes
    2015
    2015-01-01Type of plan entitySingle employer plan
    2015-01-01Submission has been amendedNo
    2015-01-01This submission is the final filingNo
    2015-01-01This return/report is a short plan year return/report (less than 12 months)No
    2015-01-01Plan is a collectively bargained planNo
    2015-01-01Plan funding arrangement – InsuranceYes
    2015-01-01Plan funding arrangement – General assets of the sponsorYes
    2015-01-01Plan benefit arrangement – InsuranceYes
    2015-01-01Plan benefit arrangement – General assets of the sponsorYes
    2014
    2014-01-01Type of plan entitySingle employer plan
    2014-01-01Submission has been amendedNo
    2014-01-01This submission is the final filingNo
    2014-01-01This return/report is a short plan year return/report (less than 12 months)No
    2014-01-01Plan is a collectively bargained planNo
    2014-01-01Plan funding arrangement – InsuranceYes
    2014-01-01Plan funding arrangement – General assets of the sponsorYes
    2014-01-01Plan benefit arrangement – InsuranceYes
    2014-01-01Plan benefit arrangement – General assets of the sponsorYes
    2013
    2013-01-01Type of plan entitySingle employer plan
    2013-01-01Submission has been amendedNo
    2013-01-01This submission is the final filingNo
    2013-01-01This return/report is a short plan year return/report (less than 12 months)No
    2013-01-01Plan is a collectively bargained planNo
    2013-01-01Plan funding arrangement – InsuranceYes
    2013-01-01Plan funding arrangement – General assets of the sponsorYes
    2013-01-01Plan benefit arrangement – InsuranceYes
    2013-01-01Plan benefit arrangement – General assets of the sponsorYes
    2012
    2012-01-01Type of plan entitySingle employer plan
    2012-01-01Submission has been amendedYes
    2012-01-01This submission is the final filingNo
    2012-01-01This return/report is a short plan year return/report (less than 12 months)No
    2012-01-01Plan is a collectively bargained planNo
    2012-01-01Plan funding arrangement – InsuranceYes
    2012-01-01Plan funding arrangement – General assets of the sponsorYes
    2012-01-01Plan benefit arrangement – InsuranceYes
    2012-01-01Plan benefit arrangement – General assets of the sponsorYes
    2011
    2011-01-01Type of plan entitySingle employer plan
    2011-01-01Submission has been amendedYes
    2011-01-01This submission is the final filingNo
    2011-01-01This return/report is a short plan year return/report (less than 12 months)No
    2011-01-01Plan is a collectively bargained planNo
    2011-01-01Plan funding arrangement – InsuranceYes
    2011-01-01Plan funding arrangement – General assets of the sponsorYes
    2011-01-01Plan benefit arrangement – InsuranceYes
    2011-01-01Plan benefit arrangement – General assets of the sponsorYes
    2009
    2009-01-01Type of plan entitySingle employer plan
    2009-01-01Submission has been amendedNo
    2009-01-01This submission is the final filingNo
    2009-01-01This return/report is a short plan year return/report (less than 12 months)No
    2009-01-01Plan is a collectively bargained planNo
    2009-01-01Plan funding arrangement – InsuranceYes
    2009-01-01Plan funding arrangement – General assets of the sponsorYes
    2009-01-01Plan benefit arrangement – InsuranceYes
    2009-01-01Plan benefit arrangement – General assets of the sponsorYes
    2008
    2008-01-01Type of plan entitySingle employer plan
    2008-01-01Submission has been amendedYes
    2008-01-01This submission is the final filingNo
    2008-01-01This return/report is a short plan year return/report (less than 12 months)No
    2008-01-01Plan is a collectively bargained planNo
    2008-01-01Plan funding arrangement – InsuranceYes
    2008-01-01Plan funding arrangement – General assets of the sponsorYes
    2008-01-01Plan benefit arrangement – InsuranceYes
    2008-01-01Plan benefit arrangement – General assets of the sponsorYes
    2007
    2007-01-01Type of plan entitySingle employer plan
    2007-01-01Submission has been amendedYes
    2007-01-01This submission is the final filingNo
    2007-01-01This return/report is a short plan year return/report (less than 12 months)No
    2007-01-01Plan is a collectively bargained planNo
    2007-01-01Plan funding arrangement – InsuranceYes
    2007-01-01Plan funding arrangement – General assets of the sponsorYes
    2007-01-01Plan benefit arrangement – InsuranceYes
    2007-01-01Plan benefit arrangement – General assets of the sponsorYes
    2006
    2006-01-01Type of plan entitySingle employer plan
    2006-01-01Submission has been amendedYes
    2006-01-01This submission is the final filingNo
    2006-01-01This return/report is a short plan year return/report (less than 12 months)No
    2006-01-01Plan is a collectively bargained planNo
    2006-01-01Plan funding arrangement – InsuranceYes
    2006-01-01Plan funding arrangement – General assets of the sponsorYes
    2006-01-01Plan benefit arrangement – InsuranceYes
    2006-01-01Plan benefit arrangement – General assets of the sponsorYes

    Insurance Providers Used on plan

    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 5
    Insurance contract or identification number538682
    Number of Individuals Covered165
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $2,904
    Total amount of fees paid to insurance companyUSD $763
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $38,159
    Commission paid to Insurance BrokerUSD $2,904
    Amount paid for insurance broker fees763
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number03247A
    Policy instance 1
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $795
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $7,950
    Commission paid to Insurance BrokerUSD $795
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097340
    Policy instance 2
    Insurance contract or identification number097340
    Number of Individuals Covered166
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $1,752
    Total amount of fees paid to insurance companyUSD $700
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $35,056
    Commission paid to Insurance BrokerUSD $1,752
    Amount paid for insurance broker fees700
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number9802570
    Policy instance 3
    Insurance contract or identification number9802570
    Number of Individuals Covered244
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $15,252
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 4
    Insurance contract or identification number097267
    Number of Individuals Covered24
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $1,661
    Total amount of fees paid to insurance companyUSD $221
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOLUNTARY LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $11,080
    Commission paid to Insurance BrokerUSD $1,661
    Amount paid for insurance broker fees221
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number03247A
    Policy instance 1
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $525
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $5,250
    Commission paid to Insurance BrokerUSD $525
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 2
    Insurance contract or identification number097267
    Number of Individuals Covered26
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $2,256
    Total amount of fees paid to insurance companyUSD $301
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $13,703
    Commission paid to Insurance BrokerUSD $2,256
    Amount paid for insurance broker fees301
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097340
    Policy instance 4
    Insurance contract or identification number097340
    Number of Individuals Covered175
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $1,600
    Total amount of fees paid to insurance companyUSD $640
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $29,337
    Commission paid to Insurance BrokerUSD $1,600
    Amount paid for insurance broker fees640
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number9802570
    Policy instance 3
    Insurance contract or identification number9802570
    Number of Individuals Covered240
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $14,244
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 5
    Insurance contract or identification number538682
    Number of Individuals Covered166
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $3,931
    Total amount of fees paid to insurance companyUSD $717
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $32,937
    Commission paid to Insurance BrokerUSD $3,931
    Amount paid for insurance broker fees717
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 5
    Insurance contract or identification number097267
    Number of Individuals Covered16
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $2,239
    Total amount of fees paid to insurance companyUSD $298
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $16,256
    Commission paid to Insurance BrokerUSD $2,239
    Amount paid for insurance broker fees298
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097340
    Policy instance 4
    Insurance contract or identification number097340
    Number of Individuals Covered170
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $1,593
    Total amount of fees paid to insurance companyUSD $637
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $34,527
    Commission paid to Insurance BrokerUSD $1,593
    Amount paid for insurance broker fees637
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
    Policy contract number03247A
    Policy instance 3
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $350
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $3,500
    Commission paid to Insurance BrokerUSD $350
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number9802570
    Policy instance 2
    Insurance contract or identification number9802570
    Number of Individuals Covered231
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $12,580
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 1
    Insurance contract or identification number538682
    Number of Individuals Covered156
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $3,572
    Total amount of fees paid to insurance companyUSD $694
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $37,654
    Commission paid to Insurance BrokerUSD $3,572
    Amount paid for insurance broker fees694
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 2
    Insurance contract or identification number097267
    Number of Individuals Covered38
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $2,407
    Total amount of fees paid to insurance companyUSD $335
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $13,382
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 3
    Insurance contract or identification number538682
    Number of Individuals Covered165
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $5,609
    Total amount of fees paid to insurance companyUSD $822
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $41,091
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097340
    Policy instance 4
    Insurance contract or identification number097340
    Number of Individuals Covered170
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,864
    Total amount of fees paid to insurance companyUSD $932
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $37,275
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 2
    Insurance contract or identification number538682
    Number of Individuals Covered165
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $5,609
    Total amount of fees paid to insurance companyUSD $822
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $41,091
    Commission paid to Insurance BrokerUSD $5,609
    Amount paid for insurance broker fees822
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097340
    Policy instance 1
    Insurance contract or identification number097340
    Number of Individuals Covered170
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,864
    Total amount of fees paid to insurance companyUSD $932
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $37,275
    Commission paid to Insurance BrokerUSD $1,864
    Amount paid for insurance broker fees932
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 3
    Insurance contract or identification number097267
    Number of Individuals Covered38
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $2,407
    Total amount of fees paid to insurance companyUSD $335
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $13,382
    Commission paid to Insurance BrokerUSD $2,407
    Amount paid for insurance broker fees335
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 4
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $350
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $3,500
    Commission paid to Insurance BrokerUSD $350
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFIT GROUP, LLC
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number9802570
    Policy instance 5
    Insurance contract or identification number9802570
    Number of Individuals Covered214
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $12,993
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number9802570
    Policy instance 1
    Insurance contract or identification number9802570
    Number of Individuals Covered214
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $12,993
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSOK600912
    Policy instance 1
    Insurance contract or identification numberSOK600912
    Number of Individuals Covered17
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $413
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&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 CarrierUSD $5,483
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 2
    Insurance contract or identification number538682
    Number of Individuals Covered176
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $1,644
    Total amount of fees paid to insurance companyUSD $431
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $34,442
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 3
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $440
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $4,400
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract number601580
    Policy instance 4
    Insurance contract or identification number601580
    Number of Individuals Covered187
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $3,569
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedSUPPLEMENTAL AND DEPENDENT 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 CarrierUSD $40,079
    DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 )
    Policy contract number34562
    Policy instance 3
    Insurance contract or identification number34562
    Number of Individuals Covered180
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $3,373
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $111,106
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number81127000
    Policy instance 1
    Insurance contract or identification number81127000
    Number of Individuals Covered14
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $6,510
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $1,467,793
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 2
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $440
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $4,400
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSOK600912
    Policy instance 4
    Insurance contract or identification numberSOK600912
    Number of Individuals Covered18
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $303
    Total amount of fees paid to insurance companyUSD $125
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedVOL LIFE AND 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 CarrierUSD $4,605
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract number601580
    Policy instance 5
    Insurance contract or identification number601580
    Number of Individuals Covered179
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $2,617
    Total amount of fees paid to insurance companyUSD $956
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedSUPPLEMENTAL AND DEPENDENT 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 CarrierUSD $35,224
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 6
    Insurance contract or identification number538682
    Number of Individuals Covered179
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $4,433
    Total amount of fees paid to insurance companyUSD $543
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $43,457
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 3
    Insurance contract or identification number538682
    Number of Individuals Covered362
    Insurance policy start date2009-01-01
    Insurance policy end date2009-12-31
    Total amount of commissions paid to insurance brokerUSD $7,479
    Total amount of fees paid to insurance companyUSD $1,124
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&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 CarrierUSD $89,912
    Commission paid to Insurance BrokerUSD $7,479
    Amount paid for insurance broker fees1124
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number81127000
    Policy instance 2
    Insurance contract or identification number81127000
    Number of Individuals Covered15
    Insurance policy start date2009-01-01
    Insurance policy end date2009-12-31
    Total amount of commissions paid to insurance brokerUSD $6,357
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $174,889
    Commission paid to Insurance BrokerUSD $6,357
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number539202
    Policy instance 1
    Insurance contract or identification number539202
    Number of Individuals Covered18
    Insurance policy start date2009-01-01
    Insurance policy end date2009-12-31
    Total amount of commissions paid to insurance brokerUSD $1,292
    Total amount of fees paid to insurance companyUSD $108
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $8,616
    Commission paid to Insurance BrokerUSD $1,292
    Amount paid for insurance broker fees108
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 4
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2009-01-01
    Insurance policy end date2009-12-31
    Total amount of commissions paid to insurance brokerUSD $280
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $2,800
    Commission paid to Insurance BrokerUSD $280
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
    Policy contract number00343351
    Policy instance 5
    Insurance contract or identification number00343351
    Number of Individuals Covered188
    Insurance policy start date2009-01-01
    Insurance policy end date2009-12-31
    Total amount of commissions paid to insurance brokerUSD $3,706
    Total amount of fees paid to insurance companyUSD $918
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $16,580
    Commission paid to Insurance BrokerUSD $3,664
    Amount paid for insurance broker fees918
    Additional information about fees paid to insurance brokerBONUS COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameFOSTER KLIMA & CO. LLC
    BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
    Policy contract numberEP877
    Policy instance 1
    Insurance contract or identification numberEP877
    Number of Individuals Covered154
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $302,672
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 2
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $300
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $3,000
    Commission paid to Insurance BrokerUSD $300
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
    Policy contract number00343351
    Policy instance 3
    Insurance contract or identification number00343351
    Number of Individuals Covered220
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $4,117
    Total amount of fees paid to insurance companyUSD $644
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $18,352
    Commission paid to Insurance BrokerUSD $4,056
    Amount paid for insurance broker fees644
    Additional information about fees paid to insurance brokerBONUS COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameFOSTER KLIMA & CO. LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number097267
    Policy instance 4
    Insurance contract or identification number097267
    Number of Individuals Covered19
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $1,014
    Total amount of fees paid to insurance companyUSD $84
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $6,761
    Commission paid to Insurance BrokerUSD $1,014
    Amount paid for insurance broker fees84
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 5
    Insurance contract or identification number538682
    Number of Individuals Covered398
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $7,645
    Total amount of fees paid to insurance companyUSD $1,216
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&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 CarrierUSD $97,308
    Commission paid to Insurance BrokerUSD $7,645
    Amount paid for insurance broker fees1216
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number81127000
    Policy instance 6
    Insurance contract or identification number81127000
    Number of Individuals Covered15
    Insurance policy start date2008-01-01
    Insurance policy end date2008-12-31
    Total amount of commissions paid to insurance brokerUSD $5,300
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $103,588
    Commission paid to Insurance BrokerUSD $5,300
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP, LLC
    CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
    Policy contract number03247A
    Policy instance 5
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $300
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $3,000
    Commission paid to Insurance BrokerUSD $300
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 6
    Insurance contract or identification number538682
    Number of Individuals Covered192
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $7,526
    Total amount of fees paid to insurance companyUSD $2,279
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&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 CarrierUSD $85,195
    Commission paid to Insurance BrokerUSD $7,526
    Amount paid for insurance broker fees2279
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number81127000
    Policy instance 4
    Insurance contract or identification number81127000
    Number of Individuals Covered16
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $4,320
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $146,188
    Commission paid to Insurance BrokerUSD $4,320
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP, LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number539202
    Policy instance 2
    Insurance contract or identification number539202
    Number of Individuals Covered15
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $728
    Total amount of fees paid to insurance companyUSD $139
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $4,854
    Commission paid to Insurance BrokerUSD $728
    Amount paid for insurance broker fees139
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFITS GROUP LLC
    BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
    Policy contract numberGP605
    Policy instance 1
    Insurance contract or identification numberGP605
    Number of Individuals Covered151
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $37,459
    Total amount of fees paid to insurance companyUSD $1,757
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $1,070,624
    Commission paid to Insurance BrokerUSD $37,459
    Amount paid for insurance broker fees1757
    Additional information about fees paid to insurance brokerCONTINGENCY FEES
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP, LLC
    THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
    Policy contract number00343351
    Policy instance 3
    Insurance contract or identification number00343351
    Number of Individuals Covered210
    Insurance policy start date2007-01-01
    Insurance policy end date2007-12-31
    Total amount of commissions paid to insurance brokerUSD $3,613
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $16,103
    Commission paid to Insurance BrokerUSD $3,559
    Insurance broker organization code?3
    Insurance broker nameFOSTER KLIMA & COMPANY LLC
    THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
    Policy contract number00343351
    Policy instance 5
    Insurance contract or identification number00343351
    Number of Individuals Covered196
    Insurance policy start date2006-01-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $3,672
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $16,673
    Commission paid to Insurance BrokerUSD $3,618
    Insurance broker organization code?3
    Insurance broker nameFOSTER KLIMA & COMPANY LLC
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number539202
    Policy instance 6
    Insurance contract or identification number539202
    Number of Individuals Covered16
    Insurance policy start date2006-01-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $849
    Total amount of fees paid to insurance companyUSD $107
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $5,873
    Commission paid to Insurance BrokerUSD $849
    Amount paid for insurance broker fees56
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameCHRISTENSEN GROUP
    BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
    Policy contract numberGP605
    Policy instance 4
    Insurance contract or identification numberGP605
    Number of Individuals Covered140
    Insurance policy start date2006-01-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $26,242
    Total amount of fees paid to insurance companyUSD $1,809
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $749,760
    Commission paid to Insurance BrokerUSD $26,242
    Amount paid for insurance broker fees1809
    Additional information about fees paid to insurance brokerCONTINGENCY FEES
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP, LLC
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number81127000
    Policy instance 3
    Insurance contract or identification number81127000
    Number of Individuals Covered13
    Insurance policy start date2006-01-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $5,364
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $109,446
    Commission paid to Insurance BrokerUSD $5,364
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS BENEFITS GROUP, LLC
    CONNETICUT GENERAL (National Association of Insurance Commissioners NAIC id number: 00000 )
    Policy contract number03247A
    Policy instance 2
    Insurance contract or identification number03247A
    Number of Individuals Covered1
    Insurance policy start date2006-11-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $180
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedMEDICAL BENEFITS ABROAD
    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 CarrierUSD $1,800
    Commission paid to Insurance BrokerUSD $180
    Insurance broker organization code?3
    Insurance broker nameHAYS BENEFIT GROUP
    UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
    Policy contract number538682
    Policy instance 1
    Insurance contract or identification number538682
    Number of Individuals Covered362
    Insurance policy start date2006-01-01
    Insurance policy end date2006-12-31
    Total amount of commissions paid to insurance brokerUSD $5,571
    Total amount of fees paid to insurance companyUSD $761
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&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 CarrierUSD $55,707
    Commission paid to Insurance BrokerUSD $5,571
    Amount paid for insurance broker fees429
    Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameCHRISTENSEN GROUP

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