HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 401k Plan overview

Plan Name	HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN
Plan identification number	520

HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

HOUGHTON MIFFLIN HARCOURT PUBLISHING COMPANY has sponsored the creation of one or more 401k plans.

Company Name:	HOUGHTON MIFFLIN HARCOURT PUBLISHING COMPANY
Employer identification number (EIN):	041456030
NAIC Classification:	511130
NAIC Description:	Book Publishers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
520	2022-01-01	ELIZABETH MARENGO	2023-09-19
520	2021-01-01	ALEJANDRO REYES	2022-09-12
520	2020-01-01	ALEJANDRO REYES	2021-08-11
520	2019-01-01	CARL CUDWORTH	2020-07-14
520	2018-01-01
520	2017-01-01
520	2016-01-01	CARL CUDWORTH
520	2015-01-01	CARL CUDWORTH
520	2014-01-01	CARL CUDWORTH
520	2013-01-01	CARL CUDWORTH
520	2012-01-01	CARL CUDWORTH
520	2011-01-01	CARL CUDWORTH
520	2010-01-01	CARL CUDWORTH
520	2009-01-01	CARL CUDWORTH		CARL CUDWORTH	2010-10-14
520	2009-01-01	CARL CUDWORTH

Plan Statistics for HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN

401k plan membership statisitcs for HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN

Measure	Date	Value
2022: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,673
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,141
Number of retired or separated participants receiving benefits	2022-01-01	538
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	2,679
2021: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	3,117
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,139
Number of retired or separated participants receiving benefits	2021-01-01	534
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	2,673
2020: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	3,838
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,401
Number of retired or separated participants receiving benefits	2020-01-01	716
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	3,117
2019: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3,990
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	3,238
Number of retired or separated participants receiving benefits	2019-01-01	600
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	3,838
2018: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	4,316
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	3,406
Number of retired or separated participants receiving benefits	2018-01-01	584
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	3,990
2017: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	4,462
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	3,580
Number of retired or separated participants receiving benefits	2017-01-01	736
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	4,316
2016: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	4,413
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	3,877
Number of retired or separated participants receiving benefits	2016-01-01	585
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	4,462
2015: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,715
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	3,763
Number of retired or separated participants receiving benefits	2015-01-01	650
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	4,413
2014: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	3,165
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	3,054
Number of retired or separated participants receiving benefits	2014-01-01	661
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	3,715
2013: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	3,283
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	2,987
Number of retired or separated participants receiving benefits	2013-01-01	178
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	3,165
2012: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	4,466
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	3,105
Number of retired or separated participants receiving benefits	2012-01-01	676
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	3,781
2011: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	3,612
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	3,545
Number of retired or separated participants receiving benefits	2011-01-01	921
Total of all active and inactive participants	2011-01-01	4,466
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	18
2010: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	3,594
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	3,588
Number of retired or separated participants receiving benefits	2010-01-01	902
Number of other retired or separated participants entitled to future benefits	2010-01-01	16
Total of all active and inactive participants	2010-01-01	4,506
2009: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	5,412
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	3,608
Number of retired or separated participants receiving benefits	2009-01-01	1,015
Number of other retired or separated participants entitled to future benefits	2009-01-01	525
Total of all active and inactive participants	2009-01-01	5,148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	100

Form 5500 Responses for HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN

2022: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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
2012: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	Yes
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HOUGHTON MIFFLIN HARCOURT PUBLISHING CO. BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	GF2-81026178701
Policy instance	4
Insurance contract or identification number GF2-81026178701 Number of Individuals Covered 2114 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $24,342 Total amount of fees paid to insurance company USD $11,823 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 $464,756 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,342 Amount paid for insurance broker fees 11823 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 95804 )
Policy contract number	112905
Policy instance	10
Insurance contract or identification number 112905 Number of Individuals Covered 1 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 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 $12,539 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 2136 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 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,953 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	2
Insurance contract or identification number 1500901 Number of Individuals Covered 273 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $5,659 Total amount of fees paid to insurance company USD $1,860 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 LEGAL 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 $55,568 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,659 Amount paid for insurance broker fees 38 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	SA2-81026178701
Policy instance	3
Insurance contract or identification number SA2-81026178701 Number of Individuals Covered 2134 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $45,015 Total amount of fees paid to insurance company USD $22,730 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $903,811 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45,015 Amount paid for insurance broker fees 22730 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009154349
Policy instance	5
Insurance contract or identification number GTP0009154349 Number of Individuals Covered 2141 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,430 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 BUSINESS TRAVEL ACCIDENT 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 $9,721 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,430 Insurance broker organization code? 3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	6
Insurance contract or identification number SP0003692 Number of Individuals Covered 7 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $5,790 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 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 $5,790 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3330046
Policy instance	7
Insurance contract or identification number 3330046 Number of Individuals Covered 3931 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $86,639 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 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 $1,756,456 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $86,639 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	06863A
Policy instance	8
Insurance contract or identification number 06863A Number of Individuals Covered 6 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,509 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 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 Other welfare benefits provided EVACUATION COVERAGE 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 $36,329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,509 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	06863A
Policy instance	9
Insurance contract or identification number 06863A Number of Individuals Covered 6 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,438 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 Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,885 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,438 Insurance broker organization code? 3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	6
Insurance contract or identification number SP0003692 Number of Individuals Covered 8 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,753 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 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 $5,753 Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 2100 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $39,731 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	2
Insurance contract or identification number 1500901 Number of Individuals Covered 249 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,619 Total amount of fees paid to insurance company USD $1,349 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 LEGAL 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 $59,322 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,619 Amount paid for insurance broker fees 67 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	SA2-81026178701
Policy instance	3
Insurance contract or identification number SA2-81026178701 Number of Individuals Covered 2102 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $43,715 Total amount of fees paid to insurance company USD $13,045 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $944,487 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,715 Amount paid for insurance broker fees 13045 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009154349
Policy instance	5
Insurance contract or identification number GTP0009154349 Number of Individuals Covered 2139 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,430 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 BUSINESS TRAVEL ACCIDENT 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 $9,721 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,430 Insurance broker organization code? 3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	GF2-81026178701
Policy instance	4
Insurance contract or identification number GF2-81026178701 Number of Individuals Covered 2097 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $23,369 Total amount of fees paid to insurance company USD $6,929 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit 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 $504,623 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,369 Amount paid for insurance broker fees 6929 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	06863A
Policy instance	8
Insurance contract or identification number 06863A Number of Individuals Covered 6 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,371 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 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 Other welfare benefits provided EVACUATION COVERAGE 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 $45,272 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,371 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3330046
Policy instance	7
Insurance contract or identification number 3330046 Number of Individuals Covered 4039 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $49,092 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 $1,950,691 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $49,092 Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 2801 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 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 EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $57,499 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	2
Insurance contract or identification number 1500901 Number of Individuals Covered 260 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,055 Total amount of fees paid to insurance company USD $1,084 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 LEGAL 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 $64,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,055 Amount paid for insurance broker fees 24 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA3-81026178701
Policy instance	3
Insurance contract or identification number SA3-81026178701 Number of Individuals Covered 2974 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $54,854 Total amount of fees paid to insurance company USD $19,510 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,007,826 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,854 Amount paid for insurance broker fees 19510 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009154349
Policy instance	5
Insurance contract or identification number GTP0009154349 Number of Individuals Covered 2401 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,612 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 BUSINESS TRAVEL ACCIDENT 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 $13,060 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,612 Insurance broker organization code? 3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	6
Insurance contract or identification number SP0003692 Number of Individuals Covered 7 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $9,265 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 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 $9,265 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3330046
Policy instance	7
Insurance contract or identification number 3330046 Number of Individuals Covered 4666 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $72,264 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 $2,224,657 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $72,264 Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF3-81026178701
Policy instance	4
Insurance contract or identification number GF3-81026178701 Number of Individuals Covered 2973 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $27,236 Total amount of fees paid to insurance company USD $9,662 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 $499,741 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,236 Amount paid for insurance broker fees 9662 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 3664 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 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 EMPLOYEE ASSISTANCE PROGRAM 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 $65,262 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	30429 1
Policy instance	2
Insurance contract or identification number 30429 1 Number of Individuals Covered 0 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 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 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 $7,141 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 321 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $7,169 Total amount of fees paid to insurance company USD $967 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 LEGAL 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 $71,691 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,169 Amount paid for insurance broker fees 42 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA3-81026178701
Policy instance	4
Insurance contract or identification number SA3-81026178701 Number of Individuals Covered 3223 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $57,054 Total amount of fees paid to insurance company USD $15,947 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,151,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,054 Amount paid for insurance broker fees 15947 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF3-81026178701
Policy instance	5
Insurance contract or identification number GF3-81026178701 Number of Individuals Covered 4423 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $29,261 Total amount of fees paid to insurance company USD $8,560 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 $582,742 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,261 Amount paid for insurance broker fees 8560 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009154349
Policy instance	7
Insurance contract or identification number GTP0009154349 Number of Individuals Covered 3442 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $2,612 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 BUSINESS TRAVEL ACCIDENT 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 $13,060 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,612 Insurance broker organization code? 3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	8
Insurance contract or identification number SP0003692 Number of Individuals Covered 14 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $10,555 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 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 $10,555 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3330046
Policy instance	9
Insurance contract or identification number 3330046 Number of Individuals Covered 5911 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $74,554 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 $2,706,938 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $74,554 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	6
Insurance contract or identification number 0143417 Number of Individuals Covered 0 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $15,060 Total amount of fees paid to insurance company USD $7,530 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 $15,060 Amount paid for insurance broker fees 7530 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 3810 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 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 EMPLOYEE ASSISTANCE PROGRAM 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 $68,650 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	30429 1
Policy instance	2
Insurance contract or identification number 30429 1 Number of Individuals Covered 1 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 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 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 $6,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 324 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,820 Total amount of fees paid to insurance company USD $1,124 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 LEGAL 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 $68,197 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,820 Amount paid for insurance broker fees 70 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA381026178701
Policy instance	4
Insurance contract or identification number SA381026178701 Number of Individuals Covered 3360 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $52,455 Total amount of fees paid to insurance company USD $19,418 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,043,688 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52,455 Amount paid for insurance broker fees 19418 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF381026178701
Policy instance	5
Insurance contract or identification number GF381026178701 Number of Individuals Covered 3349 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $29,562 Total amount of fees paid to insurance company USD $10,044 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 $602,589 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,562 Amount paid for insurance broker fees 10044 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	6
Insurance contract or identification number 0143417 Number of Individuals Covered 6042 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $96,388 Total amount of fees paid to insurance company USD $51,914 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 $3,182,190 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $96,388 Amount paid for insurance broker fees 70 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009154349
Policy instance	7
Insurance contract or identification number GTP0009154349 Number of Individuals Covered 3801 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,612 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 BUSINESS TRAVEL ACCIDENT 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 $13,060 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,612 Insurance broker organization code? 3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	8
Insurance contract or identification number SP0003692 Number of Individuals Covered 13 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $10,550 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 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 $10,550 Insurance broker organization code? 3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 3906 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 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 EMPLOYEE ASSISTANCE PROGRAM 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 $72,874 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	14405 1
Policy instance	2
Insurance contract or identification number 14405 1 Number of Individuals Covered 0 Insurance policy start date 2016-07-01 Insurance policy end date 2017-06-30 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 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 $2,589 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 289 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $6,129 Total amount of fees paid to insurance company USD $49 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 LEGAL 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 $61,294 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,129 Amount paid for insurance broker fees 49 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	SA381026178701
Policy instance	4
Insurance contract or identification number SA381026178701 Number of Individuals Covered 3570 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $55,827 Total amount of fees paid to insurance company USD $20,859 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,107,050 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,827 Amount paid for insurance broker fees 20859 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF381026178701
Policy instance	5
Insurance contract or identification number GF381026178701 Number of Individuals Covered 1646 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $22,701 Total amount of fees paid to insurance company USD $8,520 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 $450,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,701 Amount paid for insurance broker fees 8520 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	7
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3752 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,876 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 BUSINESS TRAVEL ACCIDENT 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 $9,379 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,876 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	6
Insurance contract or identification number 0143417 Number of Individuals Covered 6530 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $100,065 Total amount of fees paid to insurance company USD $62,558 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 $3,308,389 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $100,065 Amount paid for insurance broker fees 62509 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	8
Insurance contract or identification number SP0003692 Number of Individuals Covered 14 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $6,983 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 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 $6,983 Insurance broker organization code? 3 Insurance broker name MARSH SALDANA
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013562-30
Policy instance	8
Insurance contract or identification number 0013562-30 Number of Individuals Covered 1347 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $11,457 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $76,382 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,457 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 261 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,761 Total amount of fees paid to insurance company USD $904 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL 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 $46,226 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,761 Amount paid for insurance broker fees 866 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	1
Insurance contract or identification number 00000 Number of Individuals Covered 4281 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 $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $66,992 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	11
Insurance contract or identification number SP0003692 Number of Individuals Covered 13 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $6,655 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 $6,655 Insurance broker organization code? 3 Insurance broker name MARSH SALDANA
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	10
Insurance contract or identification number 645573 Number of Individuals Covered 1607 Insurance policy start date 2015-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $11,984 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,984 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	9
Insurance contract or identification number 645573 Number of Individuals Covered 3147 Insurance policy start date 2015-01-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $23,441 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,441 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	7
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3752 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,340 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $6,698 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,340 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	14405 1
Policy instance	2
Insurance contract or identification number 14405 1 Number of Individuals Covered 1 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 $7,129 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	6
Insurance contract or identification number 0143417 Number of Individuals Covered 6947 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $88,923 Total amount of fees paid to insurance company USD $57,210 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,069,249 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $88,923 Amount paid for insurance broker fees 38 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF381026178701
Policy instance	5
Insurance contract or identification number GF381026178701 Number of Individuals Covered 1539 Insurance policy start date 2015-07-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $9,256 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $185,113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,256 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract number	GF381026178701
Policy instance	4
Insurance contract or identification number GF381026178701 Number of Individuals Covered 3748 Insurance policy start date 2015-07-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $18,860 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $467,010 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,860 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number	SP0003692
Policy instance	9
Insurance contract or identification number SP0003692 Number of Individuals Covered 16 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $1,814 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 $1,814 Insurance broker organization code? 3 Insurance broker name MARSH SALDANA
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	14405 1
Policy instance	8
Insurance contract or identification number 14405 1 Number of Individuals Covered 1 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 $6,089 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	7
Insurance contract or identification number 00000 Number of Individuals Covered 3210 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 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM 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 $56,796 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	6
Insurance contract or identification number 1500901 Number of Individuals Covered 181 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,782 Total amount of fees paid to insurance company USD $571 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $37,783 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,782 Amount paid for insurance broker fees 552 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HUMAN RESOURCE CONSULTING
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	1
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3183 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $760 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $760 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013562-30
Policy instance	2
Insurance contract or identification number 0013562-30 Number of Individuals Covered 1209 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $10,695 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT 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 $10,695 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	5
Insurance contract or identification number 0143417 Number of Individuals Covered 5849 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $79,207 Total amount of fees paid to insurance company USD $41,823 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,641,981 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $79,207 Amount paid for insurance broker fees 19 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	3
Insurance contract or identification number 645573 Number of Individuals Covered 3052 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $45,015 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45,015 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	4
Insurance contract or identification number 645573 Number of Individuals Covered 1563 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $27,785 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,785 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013562-30
Policy instance	2
Insurance contract or identification number 0013562-30 Number of Individuals Covered 1243 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $11,277 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,177 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,484 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL, LLC
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000
Policy instance	7
Insurance contract or identification number 00000 Number of Individuals Covered 3108 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $56,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	6
Insurance contract or identification number 1500901 Number of Individuals Covered 179 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,242 Total amount of fees paid to insurance company USD $359 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided PRE-PAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $39,051 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,233 Amount paid for insurance broker fees 20 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	5
Insurance contract or identification number 0143417 Number of Individuals Covered 5866 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $80,956 Total amount of fees paid to insurance company USD $29,486 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,693,663 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,409 Amount paid for insurance broker fees 7101 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	4
Insurance contract or identification number 645573 Number of Individuals Covered 1578 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $36,906 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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? 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 $20,665 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	3
Insurance contract or identification number 645573 Number of Individuals Covered 2987 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $49,565 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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? 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 $28,108 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	1
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3183 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $760 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $5,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $760 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	1
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3792 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,106 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $7,372 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	3
Insurance contract or identification number 645573 Number of Individuals Covered 3074 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $40,766 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	4
Insurance contract or identification number 645573 Number of Individuals Covered 1712 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $28,564 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	5
Insurance contract or identification number 0143417 Number of Individuals Covered 6109 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $79,477 Total amount of fees paid to insurance company USD $5,965 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,796,078 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000000
Policy instance	1
Insurance contract or identification number 00000000 Number of Individuals Covered 3165 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $59,433 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013561-20
Policy instance	3
Insurance contract or identification number 0013561-20 Number of Individuals Covered 3792 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,106 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $7,372 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,106 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013562-30
Policy instance	4
Insurance contract or identification number 0013562-30 Number of Individuals Covered 1344 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $11,994 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $79,960 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,994 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL, LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	5
Insurance contract or identification number 645573 Number of Individuals Covered 3074 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $40,766 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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? 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 $40,766 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	6
Insurance contract or identification number 645573 Number of Individuals Covered 1712 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $28,564 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,564 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	7
Insurance contract or identification number 0143417 Number of Individuals Covered 6109 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $79,477 Total amount of fees paid to insurance company USD $5,965 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,796,078 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $79,477 Amount paid for insurance broker fees 5965 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	2
Insurance contract or identification number 1500901 Number of Individuals Covered 189 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,996 Total amount of fees paid to insurance company USD $84 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating 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 PREPAID LEGAL 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 $40,145 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,996 Amount paid for insurance broker fees 84 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION & NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL, LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	0013562-30
Policy instance	2
Insurance contract or identification number 0013562-30 Number of Individuals Covered 1344 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $11,994 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $79,960 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	333046
Policy instance	2
Insurance contract or identification number 333046 Number of Individuals Covered 6457 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $96,385 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $968,494 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 200 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $4,249 Total amount of fees paid to insurance company USD $908 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $39,188 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000000
Policy instance	1
Insurance contract or identification number 00000000 Number of Individuals Covered 3673 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $66,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	8
Insurance contract or identification number 645573 Number of Individuals Covered 1942 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $31,731 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	4
Insurance contract or identification number 0143417 Number of Individuals Covered 6855 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $83,661 Total amount of fees paid to insurance company USD $55,774 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,821,173 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356120
Policy instance	5
Insurance contract or identification number 001356120 Number of Individuals Covered 3884 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $995 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $6,632 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356230
Policy instance	6
Insurance contract or identification number 001356230 Number of Individuals Covered 1547 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $14,462 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $96,411 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	7
Insurance contract or identification number 645573 Number of Individuals Covered 3546 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $46,432 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 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: 47093 )
Policy contract number	30012083
Policy instance	9
Insurance contract or identification number 30012083 Number of Individuals Covered 2778 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $10,426 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	7
Insurance contract or identification number 645573 Number of Individuals Covered 3588 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $51,781 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356230
Policy instance	6
Insurance contract or identification number 001356230 Number of Individuals Covered 1600 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $14,278 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $95,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500901
Policy instance	3
Insurance contract or identification number 1500901 Number of Individuals Covered 207 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $3,878 Total amount of fees paid to insurance company USD $707 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided PREPAID LEGAL 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 $38,775 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	8
Insurance contract or identification number 645573 Number of Individuals Covered 2014 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $37,745 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 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: 47093 )
Policy contract number	30012083
Policy instance	9
Insurance contract or identification number 30012083 Number of Individuals Covered 2920 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $9,861 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $415,698 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000000
Policy instance	1
Insurance contract or identification number 00000000 Number of Individuals Covered 3682 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $66,214 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143417
Policy instance	4
Insurance contract or identification number 0143417 Number of Individuals Covered 6825 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $70,914 Total amount of fees paid to insurance company USD $47,276 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,628,653 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	333046
Policy instance	2
Insurance contract or identification number 333046 Number of Individuals Covered 3286 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $88,555 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $892,213 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356120
Policy instance	5
Insurance contract or identification number 001356120 Number of Individuals Covered 3884 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,117 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $7,447 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number	7700031000
Policy instance	2
Insurance contract or identification number 7700031000 Number of Individuals Covered 656 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $96,613 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,462,578 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $96,613 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356230
Policy instance	4
Insurance contract or identification number 001356230 Number of Individuals Covered 1657 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $14,806 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $98,705 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,806 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	001356120
Policy instance	5
Insurance contract or identification number 001356120 Number of Individuals Covered 4688 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $2,589 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 BUSINESS TRAVEL ACCIDENT 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 $17,259 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,589 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	6
Insurance contract or identification number 645573 Number of Individuals Covered 3608 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $55,695 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,695 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number	645573
Policy instance	7
Insurance contract or identification number 645573 Number of Individuals Covered 2150 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $44,346 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,346 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )
Policy contract number	30012083
Policy instance	8
Insurance contract or identification number 30012083 Number of Individuals Covered 3069 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $10,472 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $423,133 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,472 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL LLC
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00000000
Policy instance	9
Insurance contract or identification number 00000000 Number of Individuals Covered 3860 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 EMPLOYEE ASSISTANCE PROGRAM 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 $80,652 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	333046
Policy instance	1
Insurance contract or identification number 333046 Number of Individuals Covered 3563 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $85,276 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit 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 $850,575 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85,276 Insurance broker organization code? 3 Insurance broker name LONGFELLOW FINANCIAL
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00430655
Policy instance	3
Insurance contract or identification number 00430655 Number of Individuals Covered 3519 Insurance policy start date 2009-01-01 Insurance policy end date 2009-12-31 Total amount of commissions paid to insurance broker USD $68,191 Total amount of fees paid to insurance company USD $39,946 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,931,342 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,521 Amount paid for insurance broker fees 39946 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name THE BULFINCH GROUP INSURANCE AGENCY

Potentially related plans

• HOUGHTON MIFFLIN HARCOURT EMPLOYEES FEDERAL CREDIT UNION BASIC 401(K) PLAN AND TRUST [EIN = 042234540]