401k Plan data: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN plan

M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	M BLOCK & SONS, INC. WELFARE BENEFIT PLAN
Plan identification number	503

M BLOCK & SONS, INC. WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

M BLOCK & SONS, INC. has sponsored the creation of one or more 401k plans.

Company Name: M BLOCK & SONS, INC.

Employer identification number (EIN): 362087704

NAIC Classification: 423600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan M BLOCK & SONS, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2021-01-01 EDWARD ROELS 2022-04-04
503 2020-01-01 EDWARD ROELS 2021-07-21
503 2019-01-01 EDWARD ROELS 2020-07-30
503 2018-01-01
503 2017-01-01 EDWARD ROELS EDWARD ROELS 2018-07-20
503 2016-01-01 EDWARD ROELS EDWARD ROELS 2017-07-07
503 2015-01-01 EDWARD ROELS EDWARD ROELS 2016-07-21
503 2014-01-01 EDWARD ROELS EDWARD ROELS 2015-07-10
503 2013-01-01 EDWARD ROELS EDWARD ROELS 2014-11-21
503 2012-01-01 EDWARD ROELS EDWARD ROELS 2013-07-19
503 2011-01-01 EDWARD ROELS
503 2009-01-01 EDWARD ROELS
503 2009-01-01 EDWARD ROELS 2010-07-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2021-01-01	EDWARD ROELS	2022-04-04
503	2020-01-01	EDWARD ROELS	2021-07-21
503	2019-01-01	EDWARD ROELS	2020-07-30
503	2018-01-01
503	2017-01-01	EDWARD ROELS		EDWARD ROELS	2018-07-20
503	2016-01-01	EDWARD ROELS		EDWARD ROELS	2017-07-07
503	2015-01-01	EDWARD ROELS		EDWARD ROELS	2016-07-21
503	2014-01-01	EDWARD ROELS		EDWARD ROELS	2015-07-10
503	2013-01-01	EDWARD ROELS		EDWARD ROELS	2014-11-21
503	2012-01-01	EDWARD ROELS		EDWARD ROELS	2013-07-19
503	2011-01-01	EDWARD ROELS
503	2009-01-01	EDWARD ROELS
503	2009-01-01			EDWARD ROELS	2010-07-07

Plan Statistics for M BLOCK & SONS, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for M BLOCK & SONS, INC. WELFARE BENEFIT PLAN

Measure Date Value
2021: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 86
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 0
Total of all active and inactive participants 2021-01-01 0
2020: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 235
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 111
Number of retired or separated participants receiving benefits 2020-01-01 6
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 117
2019: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 280
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 229
Number of retired or separated participants receiving benefits 2019-01-01 6
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 235
2018: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 304
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 274
Number of retired or separated participants receiving benefits 2018-01-01 6
Total of all active and inactive participants 2018-01-01 280
2017: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 331
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 302
Number of retired or separated participants receiving benefits 2017-01-01 2
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 304
2016: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 363
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 329
Number of retired or separated participants receiving benefits 2016-01-01 2
Total of all active and inactive participants 2016-01-01 331
2015: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 428
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 361
Number of retired or separated participants receiving benefits 2015-01-01 2
Total of all active and inactive participants 2015-01-01 363
2014: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 395
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 426
Number of retired or separated participants receiving benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 428
2013: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 342
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 393
Number of retired or separated participants receiving benefits 2013-01-01 2
Total of all active and inactive participants 2013-01-01 395
2012: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 306
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 339
Number of retired or separated participants receiving benefits 2012-01-01 3
Total of all active and inactive participants 2012-01-01 342
Total participants 2012-01-01 342
2011: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 220
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 338
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 339
Total participants 2011-01-01 339
2009: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 165
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 162
Number of retired or separated participants receiving benefits 2009-01-01 8
Total of all active and inactive participants 2009-01-01 170
Total participants 2009-01-01 170

Measure	Date	Value
2021: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	86
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
Total of all active and inactive participants	2021-01-01	0
2020: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	235
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	111
Number of retired or separated participants receiving benefits	2020-01-01	6
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	117
2019: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	280
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	229
Number of retired or separated participants receiving benefits	2019-01-01	6
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	235
2018: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	274
Number of retired or separated participants receiving benefits	2018-01-01	6
Total of all active and inactive participants	2018-01-01	280
2017: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	331
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	302
Number of retired or separated participants receiving benefits	2017-01-01	2
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	304
2016: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	363
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	329
Number of retired or separated participants receiving benefits	2016-01-01	2
Total of all active and inactive participants	2016-01-01	331
2015: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	361
Number of retired or separated participants receiving benefits	2015-01-01	2
Total of all active and inactive participants	2015-01-01	363
2014: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	395
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	426
Number of retired or separated participants receiving benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	428
2013: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	342
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	393
Number of retired or separated participants receiving benefits	2013-01-01	2
Total of all active and inactive participants	2013-01-01	395
2012: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	306
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	339
Number of retired or separated participants receiving benefits	2012-01-01	3
Total of all active and inactive participants	2012-01-01	342
Total participants	2012-01-01	342
2011: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	220
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	338
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	339
Total participants	2011-01-01	339
2009: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	165
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	162
Number of retired or separated participants receiving benefits	2009-01-01	8
Total of all active and inactive participants	2009-01-01	170
Total participants	2009-01-01	170

Form 5500 Responses for M BLOCK & SONS, INC. WELFARE BENEFIT PLAN

2021: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	Yes
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: M BLOCK & SONS, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	12
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $421
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $131,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $421
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

0MC613/B23026

Policy instance

Insurance contract or identification number	0MC613/B23026
Number of Individuals Covered	65
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $35,244
Total amount of fees paid to insurance company	USD $2,879
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $872,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,244
Amount paid for insurance broker fees	2150
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10232014

Policy instance

Insurance contract or identification number	10232014
Number of Individuals Covered	19
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $909
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $909
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10232015

Policy instance

Insurance contract or identification number	10232015
Number of Individuals Covered	11
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $1,656
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,656
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

400001000

Policy instance

Insurance contract or identification number	400001000
Number of Individuals Covered	3
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $784
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $784
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

403004282

Policy instance

Insurance contract or identification number	403004282
Number of Individuals Covered	3
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $84
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84
Insurance broker organization code?	3

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

Policy contract number

5946301

Policy instance

Insurance contract or identification number	5946301
Number of Individuals Covered	67
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $2,686
Total amount of fees paid to insurance company	USD $929
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $57,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	882
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2,686

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	28
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $475
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $305
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232014

Policy instance

Insurance contract or identification number	000010232014
Number of Individuals Covered	106
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $1,420
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,274
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

0MC613/B23026

Policy instance

Insurance contract or identification number	0MC613/B23026
Number of Individuals Covered	183
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $45,418
Total amount of fees paid to insurance company	USD $1,656
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,161,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,124
Amount paid for insurance broker fees	1656
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232015

Policy instance

Insurance contract or identification number	000010232015
Number of Individuals Covered	88
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $2,714
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,434
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232016

Policy instance

Insurance contract or identification number	000010232016
Number of Individuals Covered	90
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $1,932
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,716
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	31
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $1,496
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,299
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	53
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $2,333
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $231,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,333
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403004282

Policy instance

Insurance contract or identification number	000403004282
Number of Individuals Covered	28
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $196
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $170
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	102
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5946301

Policy instance

Insurance contract or identification number	5946301
Number of Individuals Covered	239
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $3,155
Total amount of fees paid to insurance company	USD $169
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $70,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,918
Insurance broker organization code?	3
Amount paid for insurance broker fees	169
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	36
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $3,014
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,014
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	218
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,422
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,422
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232014

Policy instance

Insurance contract or identification number	000010232014
Number of Individuals Covered	105
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,771
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,771
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	103
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $4,237
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $425,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,237
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

0MC613/B23026

Policy instance

Insurance contract or identification number	0MC613/B23026
Number of Individuals Covered	192
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $67,309
Total amount of fees paid to insurance company	USD $1,764
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,359,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,309
Amount paid for insurance broker fees	1764
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232015

Policy instance

Insurance contract or identification number	000010232015
Number of Individuals Covered	92
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $2,838
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,838
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403004282

Policy instance

Insurance contract or identification number	000403004282
Number of Individuals Covered	34
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $366
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $366
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232016

Policy instance

Insurance contract or identification number	000010232016
Number of Individuals Covered	85
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $2,584
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,584
Insurance broker organization code?	3

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

Policy contract number

5946301

Policy instance

Insurance contract or identification number	5946301
Number of Individuals Covered	229
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $4,097
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $138,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,097
Insurance broker organization code?	3

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

Policy contract number

KM05946301

Policy instance

Insurance contract or identification number	KM05946301
Number of Individuals Covered	531
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $4,188
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $144,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,011
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	6
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $7,920
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $236,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,920
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	409
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $66,968
Total amount of fees paid to insurance company	USD $1,899
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,318,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,968
Amount paid for insurance broker fees	1899
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232015

Policy instance

Insurance contract or identification number	000010232015
Number of Individuals Covered	189
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $3,299
Total amount of fees paid to insurance company	USD $850
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,299
Amount paid for insurance broker fees	850
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	94
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $3,263
Total amount of fees paid to insurance company	USD $996
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $32,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,263
Amount paid for insurance broker fees	996
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232016

Policy instance

Insurance contract or identification number	000010232016
Number of Individuals Covered	207
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $2,763
Total amount of fees paid to insurance company	USD $1,421
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,763
Amount paid for insurance broker fees	1421
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	242
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $1,435
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $31,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,435
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403004282

Policy instance

Insurance contract or identification number	000403004282
Number of Individuals Covered	87
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $449
Total amount of fees paid to insurance company	USD $139
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD & D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $449
Amount paid for insurance broker fees	139
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	111
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $4,878
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $489,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,878
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010232014

Policy instance

Insurance contract or identification number	000010232014
Number of Individuals Covered	274
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $2,053
Total amount of fees paid to insurance company	USD $712
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD & D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,053
Amount paid for insurance broker fees	712
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	301
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $1,862
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $37,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,862
Insurance broker organization code?	3
Insurance broker name	JOHN A. CORP.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	128
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $5,256
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $522,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,256
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	364
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $10,558
Total amount of fees paid to insurance company	USD $5,730
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, OPTIONAL AD&D AND OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $351,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,558
Amount paid for insurance broker fees	5730
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	AFFILIATED BENEFIT CONSULTANTS

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	75
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $16,678
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $403,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,678
Insurance broker organization code?	3
Insurance broker name	JOHN ARAUJO

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	428
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $68,293
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,400,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,294
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	435
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $13,213
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, OPTIONAL AD&D AND OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $440,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,213
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	363
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $2,087
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $41,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,087
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	522
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $76,075
Total amount of fees paid to insurance company	USD $1,838
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,716,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,075
Amount paid for insurance broker fees	1838
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	174
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $6,646
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $619,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,646
Insurance broker organization code?	3
Insurance broker name	DANIEL F BONDI

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	95
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $26,318
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $529,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,318
Insurance broker organization code?	3
Insurance broker name	DANIEL BONDI

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	496
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $12,258
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, OPTIONAL AD&D AND OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $408,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,258
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	176
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $4,993
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $545,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,993
Insurance broker organization code?	3
Insurance broker name	DANIEL F BONDI

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	119
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $26,464
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $512,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,464
Insurance broker organization code?	3
Insurance broker name	DANIEL BONDI

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	409
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $1,961
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,961
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	543
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $66,000
Total amount of fees paid to insurance company	USD $1,074
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,337,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,000
Amount paid for insurance broker fees	1074
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	461
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $11,017
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD & D, OPTIONAL AD & D AND OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $366,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,990
Insurance broker organization code?	3
Insurance broker name	MARK C PIETSCH

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	365
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $1,790
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $35,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,790
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	124
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $27,370
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $506,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,370
Insurance broker organization code?	3
Insurance broker name	DANIEL BONDI

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	173
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $5,101
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $510,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,101
Insurance broker organization code?	3
Insurance broker name	DANIEL F BONDI

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	481
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $61,734
Total amount of fees paid to insurance company	USD $1,384
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,935,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,734
Amount paid for insurance broker fees	1384
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	154
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $4,911
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $460,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,621
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093998

Policy instance

Insurance contract or identification number	000010093998
Number of Individuals Covered	264
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $210
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093997

Policy instance

Insurance contract or identification number	000010093997
Number of Individuals Covered	365
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $126
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	98
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $215
Other welfare benefits provided	VOL LIFE, VOL AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093998

Policy instance

Insurance contract or identification number	000010093998
Number of Individuals Covered	264
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $210
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $210
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	418
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $63,682
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,949,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

124637

Policy instance

Insurance contract or identification number	124637
Number of Individuals Covered	65
Insurance policy start date	2011-12-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $15,548
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $318,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,548
Insurance broker organization code?	3
Insurance broker name	DANIEL BONDI

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	418
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $63,682
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,949,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,682
Additional information about fees paid to insurance broker	11
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	325
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $1,608
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,608
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	418
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $11,560
Total amount of fees paid to insurance company	USD $3,176
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL AD&D AND OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $266,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,560
Amount paid for insurance broker fees	3176
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	98
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $215
Other welfare benefits provided	VOL LIFE, VOL AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $215
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093999

Policy instance

Insurance contract or identification number	000010093999
Number of Individuals Covered	285
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $254
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00460047

Policy instance

Insurance contract or identification number	00460047
Number of Individuals Covered	418
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $11,560
Total amount of fees paid to insurance company	USD $3,176
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL AD&D AND OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $266,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093997

Policy instance

Insurance contract or identification number	000010093997
Number of Individuals Covered	365
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $126
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010093999

Policy instance

Insurance contract or identification number	000010093999
Number of Individuals Covered	285
Insurance policy start date	2011-08-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $254
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	325
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $1,608
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	140
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $3,539
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $356,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

400001000 06981

Policy instance

Insurance contract or identification number	400001000 06981
Number of Individuals Covered	90
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $700
Other welfare benefits provided	VOLUNTARY LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $23,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10093999 00000

Policy instance

Insurance contract or identification number	10093999 00000
Number of Individuals Covered	230
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $772
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10093997 00000

Policy instance

Insurance contract or identification number	10093997 00000
Number of Individuals Covered	214
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10093998 00000

Policy instance

Insurance contract or identification number	10093998 00000
Number of Individuals Covered	208
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $645
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	365
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $67,940
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,747,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

HB543

Policy instance

Insurance contract or identification number	HB543
Number of Individuals Covered	510
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $2,897
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	210
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $1,141
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05569680

Policy instance

Insurance contract or identification number	KM05569680
Number of Individuals Covered	392
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $188
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B23026/P23026

Policy instance

Insurance contract or identification number	B23026/P23026
Number of Individuals Covered	293
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $49,902
Total amount of fees paid to insurance company	USD $633
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,259,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,902
Amount paid for insurance broker fees	633
Additional information about fees paid to insurance broker	BONUS ON TOTAL VOLUME
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

109343

Policy instance

Insurance contract or identification number	109343
Number of Individuals Covered	100
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $1,457
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $262,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,457
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

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

Policy contract number

KM05569680

Policy instance

Insurance contract or identification number	KM05569680
Number of Individuals Covered	383
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $2,899
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,899
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

400001000 06981

Policy instance

Insurance contract or identification number	400001000 06981
Number of Individuals Covered	71
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $614
Life Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $614
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

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

Policy contract number

10093997 00000

Policy instance

Insurance contract or identification number	10093997 00000
Number of Individuals Covered	214
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $254
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10093998 00000

Policy instance

Insurance contract or identification number	10093998 00000
Number of Individuals Covered	133
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $600
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $600
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10093999 00000

Policy instance

Insurance contract or identification number	10093999 00000
Number of Individuals Covered	174
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $667
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $667
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFITS, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12241671

Policy instance

Insurance contract or identification number	12241671
Number of Individuals Covered	174
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $795
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $795
Insurance broker organization code?	3
Insurance broker name	TITAN BENEFIT, INC

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Company Name:	M BLOCK & SONS, INC.
Employer identification number (EIN):	362087704
NAIC Classification:	423600