401k Plan data: DYNA EMPIRE, INC. CAFETERIA PLAN plan

DYNA EMPIRE, INC. CAFETERIA PLAN 401k Plan overview

Plan Name	DYNA EMPIRE, INC. CAFETERIA PLAN
Plan identification number	501

DYNA EMPIRE, INC. CAFETERIA PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

DYNA-EMPIRE INC. has sponsored the creation of one or more 401k plans.

Company Name: DYNA-EMPIRE INC.

Employer identification number (EIN): 111770989

NAIC Classification: 336410

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DYNA EMPIRE, INC. CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01
501 2020-01-01
501 2018-01-01 G. PATRICK MCCARTHY
501 2017-01-01 G. PATRICK MCCARTHY
501 2016-01-01 G. PATRICK MCCARTHY
501 2015-01-01 G. PATRICK MCCARTHY
501 2014-01-01 G. PATRICK MCCARTHY
501 2013-01-01 G. PATRICK MCCARTHY
501 2012-01-01 G. PATRICK MCCARTHY
501 2011-01-01 G PATRICK MCCARTHY
501 2010-01-01 G PATRICK MCCARTHY
501 2009-01-01 G PATRICK MCCARTHY

Plan Statistics for DYNA EMPIRE, INC. CAFETERIA PLAN

401k plan membership statisitcs for DYNA EMPIRE, INC. CAFETERIA PLAN

Measure Date Value
2020: DYNA EMPIRE, INC. CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 99
Total of all active and inactive participants 2020-01-01 99
2018: DYNA EMPIRE, INC. CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 113
Total of all active and inactive participants 2018-01-01 113
Total participants 2018-01-01 113
2017: DYNA EMPIRE, INC. CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 107
Total of all active and inactive participants 2017-01-01 107
Total participants 2017-01-01 107
2016: DYNA EMPIRE, INC. CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 128
Total of all active and inactive participants 2016-01-01 128
Total participants 2016-01-01 128
2015: DYNA EMPIRE, INC. CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 131
Total of all active and inactive participants 2015-01-01 131
Total participants 2015-01-01 0
2014: DYNA EMPIRE, INC. CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 148
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 148
2013: DYNA EMPIRE, INC. CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 152
Number of retired or separated participants receiving benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 153
Total participants 2013-01-01 0
2012: DYNA EMPIRE, INC. CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 167
Number of retired or separated participants receiving benefits 2012-01-01 3
Total of all active and inactive participants 2012-01-01 170
Total participants 2012-01-01 0
2011: DYNA EMPIRE, INC. CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 180
Total of all active and inactive participants 2011-01-01 180
Total participants 2011-01-01 180
2010: DYNA EMPIRE, INC. CAFETERIA PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 174
Total of all active and inactive participants 2010-01-01 174
Total participants 2010-01-01 174
2009: DYNA EMPIRE, INC. CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 154
Total of all active and inactive participants 2009-01-01 154
Total participants 2009-01-01 154

Measure	Date	Value
2020: DYNA EMPIRE, INC. CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	99
Total of all active and inactive participants	2020-01-01	99
2018: DYNA EMPIRE, INC. CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	113
Total of all active and inactive participants	2018-01-01	113
Total participants	2018-01-01	113
2017: DYNA EMPIRE, INC. CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	107
Total of all active and inactive participants	2017-01-01	107
Total participants	2017-01-01	107
2016: DYNA EMPIRE, INC. CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	128
Total of all active and inactive participants	2016-01-01	128
Total participants	2016-01-01	128
2015: DYNA EMPIRE, INC. CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	131
Total of all active and inactive participants	2015-01-01	131
Total participants	2015-01-01	0
2014: DYNA EMPIRE, INC. CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	148
Number of retired or separated participants receiving benefits	2014-01-01	0
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	148
2013: DYNA EMPIRE, INC. CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	152
Number of retired or separated participants receiving benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	153
Total participants	2013-01-01	0
2012: DYNA EMPIRE, INC. CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	167
Number of retired or separated participants receiving benefits	2012-01-01	3
Total of all active and inactive participants	2012-01-01	170
Total participants	2012-01-01	0
2011: DYNA EMPIRE, INC. CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	180
Total of all active and inactive participants	2011-01-01	180
Total participants	2011-01-01	180
2010: DYNA EMPIRE, INC. CAFETERIA PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	174
Total of all active and inactive participants	2010-01-01	174
Total participants	2010-01-01	174
2009: DYNA EMPIRE, INC. CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	154
Total of all active and inactive participants	2009-01-01	154
Total participants	2009-01-01	154

Form 5500 Responses for DYNA EMPIRE, INC. CAFETERIA PLAN

2020: DYNA EMPIRE, INC. CAFETERIA PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2018: DYNA EMPIRE, INC. CAFETERIA PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: DYNA EMPIRE, INC. CAFETERIA PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: DYNA EMPIRE, INC. CAFETERIA PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: DYNA EMPIRE, INC. CAFETERIA PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: DYNA EMPIRE, INC. CAFETERIA PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: DYNA EMPIRE, INC. CAFETERIA PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: DYNA EMPIRE, INC. CAFETERIA PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: DYNA EMPIRE, INC. CAFETERIA PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: DYNA EMPIRE, INC. CAFETERIA PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: DYNA EMPIRE, INC. CAFETERIA PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	99
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,178
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 $58,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,178
Insurance broker organization code?	3

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	68
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,640
Total amount of fees paid to insurance company	USD $4,767
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	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 $68,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,604
Amount paid for insurance broker fees	4767
Additional information about fees paid to insurance broker	FEES
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

627017

Policy instance

Insurance contract or identification number	627017
Number of Individuals Covered	77
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $38,591
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 $927,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	38591
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	71
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,843
Total amount of fees paid to insurance company	USD $4,379
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,805
Amount paid for insurance broker fees	4379
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	105
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,466
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,466
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	112
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,087
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,087
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	113
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $148
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $148
Insurance broker organization code?	3

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1100338000

Policy instance

Insurance contract or identification number	1100338000
Number of Individuals Covered	110
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $34,107
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $886,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,107
Insurance broker organization code?	3

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,226
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,226
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $43
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $241
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
Insurance broker organization code?	3

NORTH SHORE LIJ CARECONNECT HEALTH INSURANCE INC. (National Association of Insurance Commissioners NAIC id number: 15309 )

Policy contract number

L01065

Policy instance

Insurance contract or identification number	L01065
Number of Individuals Covered	11
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $3,036
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,036
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $125
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	100
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,219
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,219
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	67
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,565
Total amount of fees paid to insurance company	USD $2,911
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,530
Amount paid for insurance broker fees	2911
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NATIONAL FINANCIAL NETWORK, LLC

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,008
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,008
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $138
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $138
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958000

Policy instance

Insurance contract or identification number	1074958000
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $24,120
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $624,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,120
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	35
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,282
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,282
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	35
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $171
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $171
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

NORTH SHORE LIJ CARECONNECT HEALTH INSURANCE INC. (National Association of Insurance Commissioners NAIC id number: 15309 )

Policy contract number

L01065

Policy instance

Insurance contract or identification number	L01065
Number of Individuals Covered	11
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,518
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,518
Insurance broker organization code?	3
Insurance broker name	COOK, HALL & HYDE, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	106
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,112
Total amount of fees paid to insurance company	USD $750
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,112
Amount paid for insurance broker fees	750
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	38
Insurance policy start date	2015-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $172
Total amount of fees paid to insurance company	USD $10
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $172
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	38
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,615
Total amount of fees paid to insurance company	USD $163
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,615
Amount paid for insurance broker fees	163
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958000

Policy instance

Insurance contract or identification number	1074958000
Number of Individuals Covered	131
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $23,473
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $734,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,473
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	113
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $143
Total amount of fees paid to insurance company	USD $66
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $143
Amount paid for insurance broker fees	66
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	113
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $953
Total amount of fees paid to insurance company	USD $438
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $953
Amount paid for insurance broker fees	438
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	75
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,609
Total amount of fees paid to insurance company	USD $3,310
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,573
Amount paid for insurance broker fees	3310
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NATIONAL FINANCIAL NETWORK, LLC

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	83
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 $4,365
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,736
Amount paid for insurance broker fees	4365
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NATIONAL FINANCIAL NETWORK

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	112
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $971
Total amount of fees paid to insurance company	USD $648
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $971
Amount paid for insurance broker fees	648
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOC INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	112
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $146
Total amount of fees paid to insurance company	USD $97
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $146
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOC INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	107
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,681
Total amount of fees paid to insurance company	USD $1,087
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,681
Amount paid for insurance broker fees	1087
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOC INC

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

007-3601-01

Policy instance

Insurance contract or identification number	007-3601-01
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $814
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $814
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOC INC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958000

Policy instance

Insurance contract or identification number	1074958000
Number of Individuals Covered	148
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $30,020
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $750,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,020
Insurance broker name	COOK MARAN & ASSOC INC

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	83
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,393
Total amount of fees paid to insurance company	USD $4,510
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,366
Amount paid for insurance broker fees	4510
Insurance broker organization code?	3
Insurance broker name	NATIONAL FINANCIAL NETWORK, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	114
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,716
Total amount of fees paid to insurance company	USD $165
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,716
Amount paid for insurance broker fees	165
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	119
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,081
Total amount of fees paid to insurance company	USD $101
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,081
Amount paid for insurance broker fees	101
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	119
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $162
Total amount of fees paid to insurance company	USD $15
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $162
Amount paid for insurance broker fees	15
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958000

Policy instance

Insurance contract or identification number	1074958000
Number of Individuals Covered	153
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $30,966
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $774,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,966
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

007-3601-01

Policy instance

Insurance contract or identification number	007-3601-01
Number of Individuals Covered	116
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,722
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,722
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	132
Insurance policy start date	2012-10-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $43
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $429
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
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	132
Insurance policy start date	2012-10-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $286
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $286
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000AMBR

Policy instance

Insurance contract or identification number	G000AMBR
Number of Individuals Covered	127
Insurance policy start date	2012-10-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $714
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $714
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC.

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958-900

Policy instance

Insurance contract or identification number	1074958-900
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958-000

Policy instance

Insurance contract or identification number	1074958-000
Number of Individuals Covered	167
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $34,000
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $850,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,000
Insurance broker organization code?	3
Insurance broker name	COOK MARAN & ASSOCIATES INC

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	87
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,603
Total amount of fees paid to insurance company	USD $6,083
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $96,400
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
Insurance broker organization code?	0
Amount paid for insurance broker fees	6083
Insurance broker name	COOK MARAN & ASSOCIATES INC

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	136
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,803
Total amount of fees paid to insurance company	USD $5,753
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $98,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958-000

Policy instance

Insurance contract or identification number	1074958-000
Number of Individuals Covered	180
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $32,710
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $817,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958-900

Policy instance

Insurance contract or identification number	1074958-900
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00441431

Policy instance

Insurance contract or identification number	00441431
Number of Individuals Covered	132
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,258
Total amount of fees paid to insurance company	USD $5,483
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $92,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,258
Amount paid for insurance broker fees	5483
Insurance broker organization code?	3
Insurance broker name	COOK HALL & HYDE, INC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1074958-000

Policy instance

Insurance contract or identification number	1074958-000
Number of Individuals Covered	174
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $29,400
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $735,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,400
Insurance broker organization code?	3
Insurance broker name	COOK HALL & HYDE INC

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Company Name:	DYNA-EMPIRE INC.
Employer identification number (EIN):	111770989
NAIC Classification:	336410