401k Plan data: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN plan

THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN
Plan identification number	501

THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

1INSURER, INC. has sponsored the creation of one or more 401k plans.

Company Name: 1INSURER, INC.

Employer identification number (EIN): 061353650

NAIC Classification: 541519
NAIC Description: Other Computer Related Services

Additional information about 1INSURER, INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 0000-00-00

Company Identification Number: 603598569

Legal Registered Office Address: 76 BATTERSON PARK RD STE 1

FARMINGTON
United States of America (USA)
060322571

More information about 1INSURER, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-10-01 DEBORAH E. GROSS
501 2013-10-01 STACIE WOLF
501 2012-10-01 STACIE WOLF
501 2011-10-01 LEWIS MILLER
501 2009-10-01 MONICA KANE

Plan id#	Filing Submission Date	Name of Administrator
501	2014-10-01	DEBORAH E. GROSS
501	2013-10-01	STACIE WOLF
501	2012-10-01	STACIE WOLF
501	2011-10-01	LEWIS MILLER
501	2009-10-01	MONICA KANE

Plan Statistics for THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN

Measure Date Value
2014: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-10-01 359
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 401
Number of retired or separated participants receiving benefits 2014-10-01 0
Number of other retired or separated participants entitled to future benefits 2014-10-01 0
Total of all active and inactive participants 2014-10-01 401
2013: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-10-01 317
Total number of active participants reported on line 7a of the Form 5500 2013-10-01 359
Number of retired or separated participants receiving benefits 2013-10-01 0
Number of other retired or separated participants entitled to future benefits 2013-10-01 0
Total of all active and inactive participants 2013-10-01 359
2012: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-10-01 307
Total number of active participants reported on line 7a of the Form 5500 2012-10-01 313
Number of retired or separated participants receiving benefits 2012-10-01 4
Total of all active and inactive participants 2012-10-01 317
2011: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-10-01 287
Total number of active participants reported on line 7a of the Form 5500 2011-10-01 307
Number of retired or separated participants receiving benefits 2011-10-01 0
Number of other retired or separated participants entitled to future benefits 2011-10-01 0
Total of all active and inactive participants 2011-10-01 307
2009: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-10-01 398
Total number of active participants reported on line 7a of the Form 5500 2009-10-01 226
Number of retired or separated participants receiving benefits 2009-10-01 0
Number of other retired or separated participants entitled to future benefits 2009-10-01 0
Total of all active and inactive participants 2009-10-01 226

Measure	Date	Value
2014: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-10-01	359
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	401
Number of retired or separated participants receiving benefits	2014-10-01	0
Number of other retired or separated participants entitled to future benefits	2014-10-01	0
Total of all active and inactive participants	2014-10-01	401
2013: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-10-01	317
Total number of active participants reported on line 7a of the Form 5500	2013-10-01	359
Number of retired or separated participants receiving benefits	2013-10-01	0
Number of other retired or separated participants entitled to future benefits	2013-10-01	0
Total of all active and inactive participants	2013-10-01	359
2012: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-10-01	307
Total number of active participants reported on line 7a of the Form 5500	2012-10-01	313
Number of retired or separated participants receiving benefits	2012-10-01	4
Total of all active and inactive participants	2012-10-01	317
2011: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-10-01	287
Total number of active participants reported on line 7a of the Form 5500	2011-10-01	307
Number of retired or separated participants receiving benefits	2011-10-01	0
Number of other retired or separated participants entitled to future benefits	2011-10-01	0
Total of all active and inactive participants	2011-10-01	307
2009: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-10-01	398
Total number of active participants reported on line 7a of the Form 5500	2009-10-01	226
Number of retired or separated participants receiving benefits	2009-10-01	0
Number of other retired or separated participants entitled to future benefits	2009-10-01	0
Total of all active and inactive participants	2009-10-01	226

Form 5500 Responses for THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN

2014: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Submission has been amended	No
2014-10-01	This submission is the final filing	No
2014-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-10-01	Plan is a collectively bargained plan	No
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2013: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-10-01	Type of plan entity	Single employer plan
2013-10-01	Submission has been amended	No
2013-10-01	This submission is the final filing	No
2013-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-10-01	Plan is a collectively bargained plan	No
2013-10-01	Plan funding arrangement – Insurance	Yes
2013-10-01	Plan benefit arrangement – Insurance	Yes
2012: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Plan funding arrangement – Insurance	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	Submission has been amended	No
2011-10-01	This submission is the final filing	No
2011-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-10-01	Plan is a collectively bargained plan	No
2011-10-01	Plan funding arrangement – Insurance	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes
2009: THE INNOVATION GROUP FLEXIBLE BENEFITS PLAN 2009 form 5500 responses
2009-10-01	Type of plan entity	Single employer plan
2009-10-01	Submission has been amended	No
2009-10-01	This submission is the final filing	No
2009-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-10-01	Plan is a collectively bargained plan	No
2009-10-01	Plan funding arrangement – Insurance	Yes
2009-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

LK751402

Policy instance

Insurance contract or identification number	LK751402
Number of Individuals Covered	285
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $6,914
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,914
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

FLX965504

Policy instance

Insurance contract or identification number	FLX965504
Number of Individuals Covered	401
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $10,671
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
Welfare Benefit Premiums Paid to Carrier	USD $71,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,671
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

30051093

Policy instance

Insurance contract or identification number	30051093
Number of Individuals Covered	191
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $2,447
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 $24,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,447
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

LK963815

Policy instance

Insurance contract or identification number	LK963815
Number of Individuals Covered	271
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $7,115
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 $47,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,115
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

OK967081

Policy instance

Insurance contract or identification number	OK967081
Number of Individuals Covered	401
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $2,935
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 & 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 $14,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,935
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337244

Policy instance

Insurance contract or identification number	3337244
Number of Individuals Covered	246
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $13,822
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $175,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,822
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

902961

Policy instance

Insurance contract or identification number	902961
Number of Individuals Covered	243
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $122,222
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 $2,520,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $122,222
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

LK751402

Policy instance

Insurance contract or identification number	LK751402
Number of Individuals Covered	359
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $5,294
Total amount of fees paid to insurance company	USD $1,140
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $35,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,355
Amount paid for insurance broker fees	1140
Additional information about fees paid to insurance broker	FEE
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9727280

Policy instance

Insurance contract or identification number	9727280
Number of Individuals Covered	247
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $3,044
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 $33,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,219
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

LK963815

Policy instance

Insurance contract or identification number	LK963815
Number of Individuals Covered	359
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $4,012
Total amount of fees paid to insurance company	USD $1,639
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 $26,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,990
Amount paid for insurance broker fees	1639
Additional information about fees paid to insurance broker	FEE
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

OK967081

Policy instance

Insurance contract or identification number	OK967081
Number of Individuals Covered	359
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,746
Total amount of fees paid to insurance company	USD $284
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 & 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 $8,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,166
Amount paid for insurance broker fees	284
Additional information about fees paid to insurance broker	FEE
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

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

Policy contract number

FLX965504

Policy instance

Insurance contract or identification number	FLX965504
Number of Individuals Covered	359
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $8,895
Total amount of fees paid to insurance company	USD $2,399
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
Welfare Benefit Premiums Paid to Carrier	USD $59,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,827
Amount paid for insurance broker fees	2399
Additional information about fees paid to insurance broker	FEE
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337244

Policy instance

Insurance contract or identification number	3337244
Number of Individuals Covered	573
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $175,006
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	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 $647,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108,258
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HP PLANNING, LLC

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51266

Policy instance

Insurance contract or identification number	51266
Number of Individuals Covered	313
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $13,546
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $203,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,546
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9727280

Policy instance

Insurance contract or identification number	9727280
Number of Individuals Covered	435
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $3,129
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,129
Insurance broker organization code?	3
Insurance broker name	THE MILLER GROUP

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9784406

Policy instance

Insurance contract or identification number	9784406
Number of Individuals Covered	9
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $16
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16
Insurance broker organization code?	3
Insurance broker name	THE MILLER GROUP

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1027053

Policy instance

Insurance contract or identification number	1027053
Number of Individuals Covered	643
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $24,446
Total amount of fees paid to insurance company	USD $2,155
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,446
Amount paid for insurance broker fees	2155
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

43544000

Policy instance

Insurance contract or identification number	43544000
Number of Individuals Covered	246
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $96,530
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,434,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96,530
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

64339000

Policy instance

Insurance contract or identification number	64339000
Number of Individuals Covered	58
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $23,204
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $575,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,204
Insurance broker organization code?	3
Insurance broker name	ROBERT E. MILLER INSURANCE AGENCY

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9727380

Policy instance

Insurance contract or identification number	9727380
Number of Individuals Covered	391
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $2,941
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 $26,986

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9784406

Policy instance

Insurance contract or identification number	9784406
Number of Individuals Covered	2
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $43
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 $458

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	405
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $3,262
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,530

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	160
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $3,766
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,942

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	160
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $2,769
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,299

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	56
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $901
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	VOLUNTARY LONG TERM DISABILITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,076

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	96
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $3,425
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	VOLUNTARY SHORT TERM DISABILITY
Were dividends 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 $12,599

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1027053

Policy instance

Insurance contract or identification number	1027053
Number of Individuals Covered	618
Insurance policy start date	2012-06-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $7,543
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	Yes
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 $50,285

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

43544000

Policy instance

Insurance contract or identification number	43544000
Number of Individuals Covered	229
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $67,301
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 $2,245,477

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

64339000

Policy instance

Insurance contract or identification number	64339000
Number of Individuals Covered	61
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $17,785
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	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 $595,452

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51266

Policy instance

Insurance contract or identification number	51266
Number of Individuals Covered	307
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $13,004
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $202,858

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	167
Insurance policy start date	2011-10-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $6,152
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	VOLUNTARY LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,094

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

64339000

Policy instance

Insurance contract or identification number	GA-819419
Number of Individuals Covered	56
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $16,101
Total amount of fees paid to insurance company	USD $1,662
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?	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,101
Insurance broker organization code?	3
Amount paid for insurance broker fees	1662
Additional information about fees paid to insurance broker	SALES/MARKETING
Welfare Benefit Premiums Paid to Carrier	USD $508,323

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

5126600000002

Policy instance

Insurance contract or identification number	5126600000002
Number of Individuals Covered	3
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
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	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 $9,095

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	386
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $3,886
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,530

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	152
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $4,516
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 $25,859

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9727380

Policy instance

Insurance contract or identification number	9727380
Number of Individuals Covered	383
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $2,936
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 $29,530

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	152
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $3,138
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,306

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	171
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $8,128
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	VOLUNTARY LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $43,786

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	66
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $1,302
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	VOLUNTARY LONG TERM DISABILITY
Were dividends 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 $7,300

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

Policy contract number

G000AFNU

Policy instance

Insurance contract or identification number	G000AFNU
Number of Individuals Covered	103
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $5,141
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	VOLUNTARY SHORT TERM DISABILITY
Were dividends 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 $22,672

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

43544000

Policy instance

Insurance contract or identification number	43544000
Number of Individuals Covered	223
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $77,838
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 $2,012,861

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )

Policy contract number

51266

Policy instance

Insurance contract or identification number	51266
Number of Individuals Covered	293
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $11,119
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $170,318

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Company Name:	1INSURER, INC.
Employer identification number (EIN):	061353650
NAIC Classification:	541519
NAIC Description:	Other Computer Related Services

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	0000-00-00
Company Identification Number:	603598569
Legal Registered Office Address:	76 BATTERSON PARK RD STE 1 FARMINGTON United States of America (USA) 060322571