401k Plan data: FIRST US BANK WELFARE BENEFITS PLAN plan

FIRST US BANK WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	FIRST US BANK WELFARE BENEFITS PLAN
Plan identification number	505

FIRST US BANK WELFARE 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

401k Sponsoring company profile

FIRST US BANK has sponsored the creation of one or more 401k plans.

Company Name: FIRST US BANK

Employer identification number (EIN): 630318800

NAIC Classification: 522110
NAIC Description: Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST US BANK WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2023-01-01 JULIETTE STAMPER 2024-06-20
505 2022-01-01 JULIETTE STAMPER 2023-07-19
505 2021-01-01 JULIETTE STAMPER 2022-05-18
505 2020-01-01 KIMBERLY PRETNAR 2021-03-31
505 2019-01-01 KIMBERLY PRETNAR 2020-07-24
505 2018-01-01 KIMBERLY PRETNAR 2019-09-27
505 2017-01-01
505 2016-01-01
505 2015-01-01
505 2014-01-01
505 2013-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
505	2023-01-01	JULIETTE STAMPER	2024-06-20
505	2022-01-01	JULIETTE STAMPER	2023-07-19
505	2021-01-01	JULIETTE STAMPER	2022-05-18
505	2020-01-01	KIMBERLY PRETNAR	2021-03-31
505	2019-01-01	KIMBERLY PRETNAR	2020-07-24
505	2018-01-01	KIMBERLY PRETNAR	2019-09-27
505	2017-01-01
505	2016-01-01
505	2015-01-01
505	2014-01-01
505	2013-01-01

Plan Statistics for FIRST US BANK WELFARE BENEFITS PLAN

401k plan membership statisitcs for FIRST US BANK WELFARE BENEFITS PLAN

Measure Date Value
2023: FIRST US BANK WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 154
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 154
2022: FIRST US BANK WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 365
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 157
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 157
2021: FIRST US BANK WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 499
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 365
Total of all active and inactive participants 2021-01-01 365
2020: FIRST US BANK WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 482
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 499
Total of all active and inactive participants 2020-01-01 499
2019: FIRST US BANK WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 505
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 482
Total of all active and inactive participants 2019-01-01 482
2018: FIRST US BANK WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 375
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 505
Total of all active and inactive participants 2018-01-01 505
2017: FIRST US BANK WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 389
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 375
Total of all active and inactive participants 2017-01-01 375
2016: FIRST US BANK WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 321
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 389
Total of all active and inactive participants 2016-01-01 389
2015: FIRST US BANK WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 321
Total of all active and inactive participants 2015-01-01 321
2014: FIRST US BANK WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 273
Total of all active and inactive participants 2014-01-01 273
2013: FIRST US BANK WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 278
Total of all active and inactive participants 2013-01-01 278

Measure	Date	Value
2023: FIRST US BANK WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	154
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	154
2022: FIRST US BANK WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	365
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	157
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	157
2021: FIRST US BANK WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	499
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	365
Total of all active and inactive participants	2021-01-01	365
2020: FIRST US BANK WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	482
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	499
Total of all active and inactive participants	2020-01-01	499
2019: FIRST US BANK WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	505
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	482
Total of all active and inactive participants	2019-01-01	482
2018: FIRST US BANK WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	375
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	505
Total of all active and inactive participants	2018-01-01	505
2017: FIRST US BANK WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	389
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	375
Total of all active and inactive participants	2017-01-01	375
2016: FIRST US BANK WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	321
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	389
Total of all active and inactive participants	2016-01-01	389
2015: FIRST US BANK WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	321
Total of all active and inactive participants	2015-01-01	321
2014: FIRST US BANK WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	273
Total of all active and inactive participants	2014-01-01	273
2013: FIRST US BANK WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	278
Total of all active and inactive participants	2013-01-01	278

Form 5500 Responses for FIRST US BANK WELFARE BENEFITS PLAN

2023: FIRST US BANK WELFARE BENEFITS PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	No
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: FIRST US BANK WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: FIRST US BANK WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FIRST US BANK WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FIRST US BANK WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FIRST US BANK WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: FIRST US BANK WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: FIRST US BANK WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: FIRST US BANK WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: FIRST US BANK WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: FIRST US BANK WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

30086195

Policy instance

Insurance contract or identification number	30086195
Number of Individuals Covered	101
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,297
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VDT962986

Policy instance

Insurance contract or identification number	VDT962986
Number of Individuals Covered	158
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,402
Total amount of fees paid to insurance company	USD $107
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 $24,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

OK970730

Policy instance

Insurance contract or identification number	OK970730
Number of Individuals Covered	158
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $510
Total amount of fees paid to insurance company	USD $17
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	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK966173

Policy instance

Insurance contract or identification number	LK966173
Number of Individuals Covered	158
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $5,026
Total amount of fees paid to insurance company	USD $165
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 $36,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX969288

Policy instance

Insurance contract or identification number	FLX969288
Number of Individuals Covered	158
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,969
Total amount of fees paid to insurance company	USD $221
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $50,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

2169FUSB

Policy instance

Insurance contract or identification number	2169FUSB
Number of Individuals Covered	113
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	PRESCRIPTION
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 $572,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HLC33571

Policy instance

Insurance contract or identification number	HLC33571
Number of Individuals Covered	110
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $178,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

30086195

Policy instance

Insurance contract or identification number	30086195
Number of Individuals Covered	94
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,338
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,338
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HLC33571

Policy instance

Insurance contract or identification number	HLC33571
Number of Individuals Covered	108
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $182,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

OK970730

Policy instance

Insurance contract or identification number	OK970730
Number of Individuals Covered	157
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $516
Total amount of fees paid to insurance company	USD $87
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	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $516
Amount paid for insurance broker fees	87
Additional information about fees paid to insurance broker	COMMISSION AND FEES OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FLX969288

Policy instance

Insurance contract or identification number	FLX969288
Number of Individuals Covered	218
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,655
Total amount of fees paid to insurance company	USD $1,047
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $44,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,655
Amount paid for insurance broker fees	1047
Additional information about fees paid to insurance broker	COMMISIONS AND FEES OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

LK966173

Policy instance

Insurance contract or identification number	LK966173
Number of Individuals Covered	157
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,973
Total amount of fees paid to insurance company	USD $851
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 $33,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,973
Amount paid for insurance broker fees	851
Additional information about fees paid to insurance broker	FEES AND COMMISSIONS OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

VDT962986

Policy instance

Insurance contract or identification number	VDT962986
Number of Individuals Covered	63
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,215
Total amount of fees paid to insurance company	USD $371
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 $21,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,215
Amount paid for insurance broker fees	371
Additional information about fees paid to insurance broker	COMMISSION & FEES OVERRIDE
Insurance broker organization code?	3

MDLIVE, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

8296311

Policy instance

Insurance contract or identification number	8296311
Number of Individuals Covered	110
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $558
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMEDICINE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $558
Insurance broker organization code?	3

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

Policy contract number

30086195

Policy instance

Insurance contract or identification number	30086195
Number of Individuals Covered	114
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,906
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,906
Additional information about fees paid to insurance broker	COMMISSIONS/FEES PAID FOR POLICY YEAR
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HLC33571

Policy instance

Insurance contract or identification number	HLC33571
Number of Individuals Covered	131
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $214,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VDT962986

Policy instance

Insurance contract or identification number	VDT962986
Number of Individuals Covered	71
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,483
Total amount of fees paid to insurance company	USD $1,227
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,483
Amount paid for insurance broker fees	1227
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

FLX969288

Policy instance

Insurance contract or identification number	FLX969288
Number of Individuals Covered	180
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,994
Total amount of fees paid to insurance company	USD $1,782
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,994
Amount paid for insurance broker fees	1782
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

LK966173

Policy instance

Insurance contract or identification number	LK966173
Number of Individuals Covered	180
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,518
Total amount of fees paid to insurance company	USD $1,456
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,518
Amount paid for insurance broker fees	1456
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

OK970730

Policy instance

Insurance contract or identification number	OK970730
Number of Individuals Covered	180
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $661
Total amount of fees paid to insurance company	USD $144
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $661
Amount paid for insurance broker fees	144
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

MDLIVE, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

8296311

Policy instance

Insurance contract or identification number	8296311
Number of Individuals Covered	126
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,604
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,604
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

2169FUSB

Policy instance

Insurance contract or identification number	2169FUSB
Number of Individuals Covered	129
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,975
Welfare Benefit Premiums Paid to Carrier	USD $523,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2975
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	4

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HLC33571

Policy instance

Insurance contract or identification number	HLC33571
Number of Individuals Covered	184
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $180,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

30086195

Policy instance

Insurance contract or identification number	30086195
Number of Individuals Covered	160
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,072
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,072
Additional information about fees paid to insurance broker	COMMISSIONS/FEES PAID FOR POLICY YEAR
Insurance broker organization code?	3

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

Policy contract number

FLX969288

Policy instance

Insurance contract or identification number	FLX969288
Number of Individuals Covered	259
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,063
Total amount of fees paid to insurance company	USD $2,852
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,063
Amount paid for insurance broker fees	2852
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

LK966173

Policy instance

Insurance contract or identification number	LK966173
Number of Individuals Covered	259
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,340
Total amount of fees paid to insurance company	USD $2,306
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,340
Amount paid for insurance broker fees	2306
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

OK970730

Policy instance

Insurance contract or identification number	OK970730
Number of Individuals Covered	259
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $329
Total amount of fees paid to insurance company	USD $226
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Amount paid for insurance broker fees	226
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

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

Policy contract number

VDT962986

Policy instance

Insurance contract or identification number	VDT962986
Number of Individuals Covered	93
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Total amount of fees paid to insurance company	USD $1,594
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,004
Amount paid for insurance broker fees	1594
Additional information about fees paid to insurance broker	BASE COMMISSIONS AND FEES
Insurance broker organization code?	3

MDLIVE, INC. (National Association of Insurance Commissioners NAIC id number: 51825 )

Policy contract number

8296311

Policy instance

Insurance contract or identification number	8296311
Number of Individuals Covered	182
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,450
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,450
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

2169FUSB

Policy instance

Insurance contract or identification number	2169FUSB
Number of Individuals Covered	186
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,375
Welfare Benefit Premiums Paid to Carrier	USD $499,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3375
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	4

MDLIVE, INC. (National Association of Insurance Commissioners NAIC id number: 51825 )

Policy contract number

8296311

Policy instance

Insurance contract or identification number	8296311
Number of Individuals Covered	188
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,431
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,431
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

5923521

Policy instance

Insurance contract or identification number	5923521
Number of Individuals Covered	482
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $19,100
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $151,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,100
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

30086195

Policy instance

Insurance contract or identification number	30086195
Number of Individuals Covered	165
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,774
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,774
Additional information about fees paid to insurance broker	COMMISSIONS/FEES PAID FOR POLICY YEAR
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HLC33571

Policy instance

Insurance contract or identification number	HLC33571
Number of Individuals Covered	192
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $192,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL33571

Policy instance

Insurance contract or identification number	HCL33571
Number of Individuals Covered	188
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $144,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

646118

Policy instance

Insurance contract or identification number	646118
Number of Individuals Covered	148
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,349
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,349
Additional information about fees paid to insurance broker	COMMISSIONS

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	505
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,723
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,723
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	505
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,452
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,452
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	505
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $604
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $604
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	505
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,592
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,592
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	375
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,254
Total amount of fees paid to insurance company	USD $123
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,632
Amount paid for insurance broker fees	123
Additional information about fees paid to insurance broker	BASE COMMISSIONS & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	S S NESBITT & CO, INC.

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	375
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $567
Total amount of fees paid to insurance company	USD $14
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $335
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	BASE COMMISSIONS & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	S S NESBITT & CO, INC.

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	375
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,635
Total amount of fees paid to insurance company	USD $95
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,286
Amount paid for insurance broker fees	95
Additional information about fees paid to insurance broker	BASE COMMISSIONS & SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	S S NESBITT & CO, INC.

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	375
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,880
Total amount of fees paid to insurance company	USD $123
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,991
Amount paid for insurance broker fees	123
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BASE COMMISSIONS
Insurance broker name	S S NESBITT & CO, INC.

ALLIANCE INSURANCE GROUP LLC (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

AIG4424

Policy instance

Insurance contract or identification number	AIG4424
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,056
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,056
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

646118

Policy instance

Insurance contract or identification number	646118
Number of Individuals Covered	122
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,074
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,137
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	S S NESBITT & CO, INC.

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3287463

Policy instance

Insurance contract or identification number	E3287463
Number of Individuals Covered	53
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,718
Total amount of fees paid to insurance company	USD $2
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $47,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,637
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	2
Insurance broker name	STACIA ROBINSON

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3913993

Policy instance

Insurance contract or identification number	E3913993
Number of Individuals Covered	24
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,297
Total amount of fees paid to insurance company	USD $2
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $19,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $564
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	2
Insurance broker name	ANGIE CARMACK LETT

ALLIANCE INSURANCE GROUP LLC (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

AIG4424

Policy instance

Insurance contract or identification number	AIG4424
Number of Individuals Covered	55
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,984
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,984
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	321
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,854
Total amount of fees paid to insurance company	USD $1,116
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,854
Amount paid for insurance broker fees	1116
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	321
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $598
Total amount of fees paid to insurance company	USD $98
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $598
Amount paid for insurance broker fees	98
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	321
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,792
Total amount of fees paid to insurance company	USD $780
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,792
Amount paid for insurance broker fees	780
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

TM05923521

Policy instance

Insurance contract or identification number	TM05923521
Number of Individuals Covered	321
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,689
Total amount of fees paid to insurance company	USD $592
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,689
Amount paid for insurance broker fees	592
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

ALLIANCE INSURANCE GROUP LLC (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

AIG4424

Policy instance

Insurance contract or identification number	AIG4424
Number of Individuals Covered	187
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,039
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,039
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

00494247

Policy instance

Insurance contract or identification number	00494247
Number of Individuals Covered	160
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,683
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4683
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

650140

Policy instance

Insurance contract or identification number	650140
Number of Individuals Covered	335
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $78,337
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,434,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,337
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

646118

Policy instance

Insurance contract or identification number	646118
Number of Individuals Covered	107
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,866
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,866
Insurance broker name	MICHAEL G. HICKS

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3287463

Policy instance

Insurance contract or identification number	E3287463
Number of Individuals Covered	71
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,563
Total amount of fees paid to insurance company	USD $22
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $72,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,625
Insurance broker organization code?	3
Amount paid for insurance broker fees	18
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker name	ANGIE CARMACK LETT

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	51
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $2,061
Total amount of fees paid to insurance company	USD $337
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,061
Amount paid for insurance broker fees	337
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	273
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,791
Total amount of fees paid to insurance company	USD $688
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,791
Amount paid for insurance broker fees	688
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	273
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,624
Total amount of fees paid to insurance company	USD $671
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,624
Amount paid for insurance broker fees	671
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	90
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,083
Total amount of fees paid to insurance company	USD $519
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,083
Amount paid for insurance broker fees	519
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

ALLIANCE INSURANCE GROUP LLC (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

AIG4424

Policy instance

Insurance contract or identification number	AIG4424
Number of Individuals Covered	177
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,048
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,048
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

00494247

Policy instance

Insurance contract or identification number	00494247
Number of Individuals Covered	180
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

650140

Policy instance

Insurance contract or identification number	650140
Number of Individuals Covered	342
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $63,646
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,722,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,646
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	97
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $3,198
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,198
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	278
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $4,505
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,505
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	278
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $4,686
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,686
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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

Policy contract number

G000AN79

Policy instance

Insurance contract or identification number	G000AN79
Number of Individuals Covered	59
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $2,010
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,010
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	ALLIANCE INSURANCE GROUP LLC

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Company Name:	FIRST US BANK
Employer identification number (EIN):	630318800
NAIC Classification:	522110
NAIC Description:	Commercial Banking