401k Plan data: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN plan

THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN
Plan identification number	501

THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

THE LITTLE POTATO COMPANY USA, INC. has sponsored the creation of one or more 401k plans.

Company Name: THE LITTLE POTATO COMPANY USA, INC.

Employer identification number (EIN): 474247349

NAIC Classification: 311400
NAIC Description: Fruit and Vegetable Preserving and Specialty Food Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-09-01
501 2021-09-01
501 2020-09-01
501 2019-09-01
501 2018-09-01

Plan Statistics for THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-09-01 109
Total number of active participants reported on line 7a of the Form 5500 2022-09-01 108
Number of retired or separated participants receiving benefits 2022-09-01 1
Number of other retired or separated participants entitled to future benefits 2022-09-01 0
Total of all active and inactive participants 2022-09-01 109
2021: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-09-01 109
Total number of active participants reported on line 7a of the Form 5500 2021-09-01 108
Number of retired or separated participants receiving benefits 2021-09-01 1
Number of other retired or separated participants entitled to future benefits 2021-09-01 0
Total of all active and inactive participants 2021-09-01 109
2020: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-09-01 122
Total number of active participants reported on line 7a of the Form 5500 2020-09-01 113
Number of retired or separated participants receiving benefits 2020-09-01 0
Number of other retired or separated participants entitled to future benefits 2020-09-01 0
Total of all active and inactive participants 2020-09-01 113
2019: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 104
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 119
Number of retired or separated participants receiving benefits 2019-09-01 3
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 122
2018: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-09-01 114
Total number of active participants reported on line 7a of the Form 5500 2018-09-01 119
Number of retired or separated participants receiving benefits 2018-09-01 1
Number of other retired or separated participants entitled to future benefits 2018-09-01 20
Total of all active and inactive participants 2018-09-01 140

Measure	Date	Value
2022: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-09-01	109
Total number of active participants reported on line 7a of the Form 5500	2022-09-01	108
Number of retired or separated participants receiving benefits	2022-09-01	1
Number of other retired or separated participants entitled to future benefits	2022-09-01	0
Total of all active and inactive participants	2022-09-01	109
2021: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-09-01	109
Total number of active participants reported on line 7a of the Form 5500	2021-09-01	108
Number of retired or separated participants receiving benefits	2021-09-01	1
Number of other retired or separated participants entitled to future benefits	2021-09-01	0
Total of all active and inactive participants	2021-09-01	109
2020: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-09-01	122
Total number of active participants reported on line 7a of the Form 5500	2020-09-01	113
Number of retired or separated participants receiving benefits	2020-09-01	0
Number of other retired or separated participants entitled to future benefits	2020-09-01	0
Total of all active and inactive participants	2020-09-01	113
2019: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	104
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	119
Number of retired or separated participants receiving benefits	2019-09-01	3
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	122
2018: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-09-01	114
Total number of active participants reported on line 7a of the Form 5500	2018-09-01	119
Number of retired or separated participants receiving benefits	2018-09-01	1
Number of other retired or separated participants entitled to future benefits	2018-09-01	20
Total of all active and inactive participants	2018-09-01	140

Form 5500 Responses for THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN

2022: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-09-01	Type of plan entity	Single employer plan
2022-09-01	Submission has been amended	No
2022-09-01	This submission is the final filing	No
2022-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-09-01	Plan is a collectively bargained plan	No
2022-09-01	Plan funding arrangement – Insurance	Yes
2022-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-09-01	Plan benefit arrangement – Insurance	Yes
2022-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-09-01	Type of plan entity	Single employer plan
2021-09-01	Submission has been amended	No
2021-09-01	This submission is the final filing	No
2021-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-09-01	Plan is a collectively bargained plan	No
2021-09-01	Plan funding arrangement – Insurance	Yes
2021-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-09-01	Plan benefit arrangement – Insurance	Yes
2021-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-09-01	Type of plan entity	Single employer plan
2020-09-01	Submission has been amended	No
2020-09-01	This submission is the final filing	No
2020-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-09-01	Plan is a collectively bargained plan	No
2020-09-01	Plan funding arrangement – Insurance	Yes
2020-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-09-01	Plan benefit arrangement – Insurance	Yes
2020-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	Submission has been amended	No
2019-09-01	This submission is the final filing	No
2019-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-09-01	Plan is a collectively bargained plan	No
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: THE LITTLE POTATO COMPANY USA, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-09-01	Type of plan entity	Single employer plan
2018-09-01	First time form 5500 has been submitted	Yes
2018-09-01	Submission has been amended	No
2018-09-01	This submission is the final filing	No
2018-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-09-01	Plan is a collectively bargained plan	No
2018-09-01	Plan funding arrangement – Insurance	Yes
2018-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-09-01	Plan benefit arrangement – Insurance	Yes
2018-09-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	109
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $1,372
Total amount of fees paid to insurance company	USD $306
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 $14,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,372
Amount paid for insurance broker fees	306
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	109
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $2,970
Total amount of fees paid to insurance company	USD $780
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $35,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,970
Amount paid for insurance broker fees	780
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )

Policy contract number

41596 00000

Policy instance

Insurance contract or identification number	41596 00000
Number of Individuals Covered	72
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $694
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 $8,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $694
Insurance broker organization code?	3

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

Policy contract number

00552136

Policy instance

Insurance contract or identification number	00552136
Number of Individuals Covered	17
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $2,284
Total amount of fees paid to insurance company	USD $111
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,251
Amount paid for insurance broker fees	111
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 )

Policy contract number

902381

Policy instance

Insurance contract or identification number	902381
Number of Individuals Covered	182
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $18,004
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 $931,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,004
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	109
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $2,641
Total amount of fees paid to insurance company	USD $414
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 $18,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,641
Amount paid for insurance broker fees	414
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	25
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $1,437
Total amount of fees paid to insurance company	USD $267
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, SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $14,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,437
Amount paid for insurance broker fees	267
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	229
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $2,920
Total amount of fees paid to insurance company	USD $496
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Amount paid for insurance broker fees	496
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )

Policy contract number

41596 00000

Policy instance

Insurance contract or identification number	41596 00000
Number of Individuals Covered	74
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $685
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 $8,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $685
Insurance broker organization code?	3

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

Policy contract number

00552136

Policy instance

Insurance contract or identification number	00552136
Number of Individuals Covered	17
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $1,600
Total amount of fees paid to insurance company	USD $285
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,584
Amount paid for insurance broker fees	285
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 )

Policy contract number

902381

Policy instance

Insurance contract or identification number	902381
Number of Individuals Covered	185
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $18,468
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 $791,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,468
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	229
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $2,579
Total amount of fees paid to insurance company	USD $264
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 $18,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,579
Amount paid for insurance broker fees	264
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	26
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $1,150
Total amount of fees paid to insurance company	USD $167
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, SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $11,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,150
Amount paid for insurance broker fees	167
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	226
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $1,328
Total amount of fees paid to insurance company	USD $195
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 $13,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,328
Amount paid for insurance broker fees	195
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	133
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $2,820
Total amount of fees paid to insurance company	USD $476
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $32,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,820
Amount paid for insurance broker fees	476
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )

Policy contract number

41596 00000

Policy instance

Insurance contract or identification number	41596 00000
Number of Individuals Covered	75
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $722
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 $9,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $722
Insurance broker organization code?	3

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

Policy contract number

00552136

Policy instance

Insurance contract or identification number	00552136
Number of Individuals Covered	17
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,913
Total amount of fees paid to insurance company	USD $308
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,886
Amount paid for insurance broker fees	308
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 )

Policy contract number

902381

Policy instance

Insurance contract or identification number	902381
Number of Individuals Covered	186
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $19,241
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 $822,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,241
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	26
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,069
Total amount of fees paid to insurance company	USD $133
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, SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $10,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,069
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	133
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,275
Total amount of fees paid to insurance company	USD $183
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 $12,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,275
Amount paid for insurance broker fees	183
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

07518 00000

Policy instance

Insurance contract or identification number	07518 00000
Number of Individuals Covered	86
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $4,859
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,859
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	133
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $2,476
Total amount of fees paid to insurance company	USD $253
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 $17,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,476
Amount paid for insurance broker fees	253
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	143
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $1,263
Total amount of fees paid to insurance company	USD $197
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 $12,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,263
Amount paid for insurance broker fees	197
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

07518 00000

Policy instance

Insurance contract or identification number	07518 00000
Number of Individuals Covered	90
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $4,865
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,865
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	143
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $2,812
Total amount of fees paid to insurance company	USD $497
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $32,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,812
Amount paid for insurance broker fees	497
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )

Policy contract number

41596 00000

Policy instance

Insurance contract or identification number	41596 00000
Number of Individuals Covered	79
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $700
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 $8,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $700
Insurance broker organization code?	3

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

Policy contract number

00552136

Policy instance

Insurance contract or identification number	00552136
Number of Individuals Covered	16
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $1,965
Total amount of fees paid to insurance company	USD $453
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,935
Amount paid for insurance broker fees	453
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	145
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $2,976
Total amount of fees paid to insurance company	USD $824
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,976
Insurance broker organization code?	3
Amount paid for insurance broker fees	824
Additional information about fees paid to insurance broker	FEES

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	145
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $3,118
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 $18,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,657
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	34
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $957
Total amount of fees paid to insurance company	USD $363
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	SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $9,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $957
Insurance broker organization code?	3
Amount paid for insurance broker fees	363
Additional information about fees paid to insurance broker	FEES

UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 )

Policy contract number

902381

Policy instance

Insurance contract or identification number	902381
Number of Individuals Covered	196
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $16,626
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 $839,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,626
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	146
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $1,713
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 $13,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,378
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	143
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $2,459
Total amount of fees paid to insurance company	USD $264
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 $17,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,459
Amount paid for insurance broker fees	264
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	28
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $850
Total amount of fees paid to insurance company	USD $141
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, SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $8,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $850
Amount paid for insurance broker fees	141
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

07518 00000

Policy instance

Insurance contract or identification number	07518 00000
Number of Individuals Covered	89
Insurance policy start date	2018-12-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $3,327
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,327
Insurance broker organization code?	3

WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )

Policy contract number

41596 00000

Policy instance

Insurance contract or identification number	41596 00000
Number of Individuals Covered	82
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $639
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 $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 $639
Insurance broker organization code?	3

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

Policy contract number

00552136

Policy instance

Insurance contract or identification number	00552136
Number of Individuals Covered	22
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $2,545
Total amount of fees paid to insurance company	USD $272
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,447
Amount paid for insurance broker fees	272
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165804

Policy instance

Insurance contract or identification number	G 165804
Number of Individuals Covered	65
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,925
Total amount of fees paid to insurance company	USD $110
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,925
Insurance broker organization code?	3
Amount paid for insurance broker fees	110
Additional information about fees paid to insurance broker	FEES

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 129139

Policy instance

Insurance contract or identification number	LTD 129139
Number of Individuals Covered	65
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,549
Total amount of fees paid to insurance company	USD $62
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 $10,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,549
Insurance broker organization code?	3
Amount paid for insurance broker fees	62
Additional information about fees paid to insurance broker	FEES

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186656

Policy instance

Insurance contract or identification number	VG 186656
Number of Individuals Covered	25
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $843
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	SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT 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 $8,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $843
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158181

Policy instance

Insurance contract or identification number	GL 158181
Number of Individuals Covered	66
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $778
Total amount of fees paid to insurance company	USD $29
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 $7,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $778
Insurance broker organization code?	3
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	FEES

UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 )

Policy contract number

902381

Policy instance

Insurance contract or identification number	902381
Number of Individuals Covered	198
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $16,157
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 $977,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,157
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

27016 00357

Policy instance

Insurance contract or identification number	27016 00357
Number of Individuals Covered	89
Insurance policy start date	2018-09-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $542
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 $15,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $542
Insurance broker organization code?	3

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Company Name:	THE LITTLE POTATO COMPANY USA, INC.
Employer identification number (EIN):	474247349
NAIC Classification:	311400
NAIC Description:	Fruit and Vegetable Preserving and Specialty Food Manufacturing