401k Plan data: MEDICAL DEPOT MEDICAL INSURANCE PLAN plan

MEDICAL DEPOT MEDICAL INSURANCE PLAN 401k Plan overview

Plan Name	MEDICAL DEPOT MEDICAL INSURANCE PLAN
Plan identification number	501

MEDICAL DEPOT MEDICAL INSURANCE 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

MEDICAL DEPOT, INC. has sponsored the creation of one or more 401k plans.

Company Name: MEDICAL DEPOT, INC.

Employer identification number (EIN): 113525013

NAIC Classification: 339110

Additional information about MEDICAL DEPOT, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2016-02-22

Company Identification Number: 0802397239

Legal Registered Office Address: 99 SEAVIEW BLVD STE 210

PRT WASHINGTN
United States of America (USA)
11050

More information about MEDICAL DEPOT, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MEDICAL DEPOT MEDICAL INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 MINDY KIRSCH
501 2017-01-01 MINDY KIRSCH
501 2017-01-01 MINDY KIRSCH
501 2016-01-01 CRAIG ZUMBO
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 RICHARD KOLODNY
501 2011-01-01 RICHARD KOLODNY

Plan Statistics for MEDICAL DEPOT MEDICAL INSURANCE PLAN

401k plan membership statisitcs for MEDICAL DEPOT MEDICAL INSURANCE PLAN

Measure Date Value
2022: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,143
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 798
Number of retired or separated participants receiving benefits 2022-01-01 57
Number of other retired or separated participants entitled to future benefits 2022-01-01 53
Total of all active and inactive participants 2022-01-01 908
2021: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,144
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,096
Number of retired or separated participants receiving benefits 2021-01-01 54
Number of other retired or separated participants entitled to future benefits 2021-01-01 17
Total of all active and inactive participants 2021-01-01 1,167
2020: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,091
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,019
Number of retired or separated participants receiving benefits 2020-01-01 11
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 1,030
2019: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,083
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,040
Number of retired or separated participants receiving benefits 2019-01-01 50
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 1,090
2018: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 813
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 811
Number of retired or separated participants receiving benefits 2018-01-01 9
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 820
2017: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 711
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 804
Number of retired or separated participants receiving benefits 2017-01-01 15
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 819
2016: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 610
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 775
Number of retired or separated participants receiving benefits 2016-01-01 12
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 787
2015: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 487
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 636
Total of all active and inactive participants 2015-01-01 636
2014: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 446
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 487
Total of all active and inactive participants 2014-01-01 487
2013: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 362
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 446
Total of all active and inactive participants 2013-01-01 446
2012: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 276
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 362
Total of all active and inactive participants 2012-01-01 362
2011: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 276
Total of all active and inactive participants 2011-01-01 276

Measure	Date	Value
2022: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,143
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	798
Number of retired or separated participants receiving benefits	2022-01-01	57
Number of other retired or separated participants entitled to future benefits	2022-01-01	53
Total of all active and inactive participants	2022-01-01	908
2021: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,144
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,096
Number of retired or separated participants receiving benefits	2021-01-01	54
Number of other retired or separated participants entitled to future benefits	2021-01-01	17
Total of all active and inactive participants	2021-01-01	1,167
2020: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,091
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,019
Number of retired or separated participants receiving benefits	2020-01-01	11
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	1,030
2019: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,083
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,040
Number of retired or separated participants receiving benefits	2019-01-01	50
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	1,090
2018: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	813
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	811
Number of retired or separated participants receiving benefits	2018-01-01	9
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	820
2017: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	711
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	804
Number of retired or separated participants receiving benefits	2017-01-01	15
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	819
2016: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	610
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	775
Number of retired or separated participants receiving benefits	2016-01-01	12
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	787
2015: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	487
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	636
Total of all active and inactive participants	2015-01-01	636
2014: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	446
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	487
Total of all active and inactive participants	2014-01-01	487
2013: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	362
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	446
Total of all active and inactive participants	2013-01-01	446
2012: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	276
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	362
Total of all active and inactive participants	2012-01-01	362
2011: MEDICAL DEPOT MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	276
Total of all active and inactive participants	2011-01-01	276

Form 5500 Responses for MEDICAL DEPOT MEDICAL INSURANCE PLAN

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

Insurance Providers Used on plan

UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	251
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	1098
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $215,603
Total amount of fees paid to insurance company	USD $4,820
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $5,811,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $215,603
Insurance broker organization code?	3
Amount paid for insurance broker fees	4820
Additional information about fees paid to insurance broker	FEES PAID

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99080711*

Policy instance

Insurance contract or identification number	99080711*
Number of Individuals Covered	798
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

954143

Policy instance

Insurance contract or identification number	954143
Number of Individuals Covered	72
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $312
Total amount of fees paid to insurance company	USD $105
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
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 $12,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $312
Amount paid for insurance broker fees	105
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0801225

Policy instance

Insurance contract or identification number	R0801225
Number of Individuals Covered	78
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,192
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	HOSPITAL INDEMNITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,192
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

694096

Policy instance

Insurance contract or identification number	694096
Number of Individuals Covered	68
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,796
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,796
Insurance broker organization code?	3

ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	843
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $33,133
Total amount of fees paid to insurance company	USD $7,544
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	Yes
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 $478,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $33,133
Insurance broker organization code?	3
Amount paid for insurance broker fees	7544
Additional information about fees paid to insurance broker	FEES PAID

ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	1084
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,536
Total amount of fees paid to insurance company	USD $7,136
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	Yes
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 $447,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $26,536
Insurance broker organization code?	3
Amount paid for insurance broker fees	7136
Additional information about fees paid to insurance broker	FEES PAID

UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	336
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,536
Total amount of fees paid to insurance company	USD $7,136
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $265,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $26,536
Insurance broker organization code?	3
Amount paid for insurance broker fees	7136
Additional information about fees paid to insurance broker	FEES PAID

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	1284
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $213,318
Total amount of fees paid to insurance company	USD $4,870
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $5,536,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $213,318
Insurance broker organization code?	3
Amount paid for insurance broker fees	4870
Additional information about fees paid to insurance broker	FEES PAID

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99080711*

Policy instance

Insurance contract or identification number	99080711*
Number of Individuals Covered	1096
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

954143

Policy instance

Insurance contract or identification number	954143
Number of Individuals Covered	75
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $229
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $582
Amount paid for insurance broker fees	229
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0801225

Policy instance

Insurance contract or identification number	R0801225
Number of Individuals Covered	76
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,128
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	HOSPITAL INDEMNITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,128
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

694096

Policy instance

Insurance contract or identification number	694096
Number of Individuals Covered	56
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,401
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,401
Insurance broker organization code?	3

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	844
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $203,023
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,382,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203,023
Insurance broker organization code?	3

FIDELITY SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 67288 )

Policy contract number

5100

Policy instance

Insurance contract or identification number	5100
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,013
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,470
Insurance broker organization code?	3

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

10248315*

Policy instance

Insurance contract or identification number	10248315*
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $52,895
Total amount of fees paid to insurance company	USD $30,420
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
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 $777,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,895
Insurance broker organization code?	3
Amount paid for insurance broker fees	30420
Additional information about fees paid to insurance broker	BROKER BONUS

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99080711

Policy instance

Insurance contract or identification number	99080711
Number of Individuals Covered	1019
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,517
Total amount of fees paid to insurance company	USD $1,981
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $43,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,517
Amount paid for insurance broker fees	1981
Additional information about fees paid to insurance broker	CONTINGENT COMMISSION
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

954143

Policy instance

Insurance contract or identification number	954143
Number of Individuals Covered	50
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $372
Total amount of fees paid to insurance company	USD $186
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
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 $7,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $372
Amount paid for insurance broker fees	186
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0801225

Policy instance

Insurance contract or identification number	R0801225
Number of Individuals Covered	48
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $732
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	HOSPITAL INDEMNITY
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 $7,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $732
Insurance broker organization code?	3

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	978
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $191,614
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	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 $5,731,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $191,614
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB120003

Policy instance

Insurance contract or identification number	ETB120003
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $375
Total amount of fees paid to insurance company	USD $14
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $375
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

FIDELITY SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 67288 )

Policy contract number

5100

Policy instance

Insurance contract or identification number	5100
Number of Individuals Covered	1110
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,211
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $62,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,211
Insurance broker organization code?	3

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

10248315*

Policy instance

Insurance contract or identification number	10248315*
Number of Individuals Covered	1075
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $54,116
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
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 $811,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,116
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99080711

Policy instance

Insurance contract or identification number	99080711
Number of Individuals Covered	671
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,293
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,293
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB120003

Policy instance

Insurance contract or identification number	ETB120003
Number of Individuals Covered	811
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $410
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $410
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

14990914

Policy instance

Insurance contract or identification number	14990914
Number of Individuals Covered	14
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $1,548
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,548
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

05913-659*

Policy instance

Insurance contract or identification number	05913-659*
Number of Individuals Covered	30
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,957
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $152,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,957
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

90996

Policy instance

Insurance contract or identification number	90996
Number of Individuals Covered	2
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $2,439
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,439
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

90996

Policy instance

Insurance contract or identification number	90996
Number of Individuals Covered	23
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $14,794
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,794
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

90996

Policy instance

Insurance contract or identification number	90996
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,161
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,161
Insurance broker organization code?	3

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $713
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	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 $17,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $426
Insurance broker organization code?	3

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

Policy contract number

730081

Policy instance

Insurance contract or identification number	730081
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $69,992
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,749,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,019
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

14990914

Policy instance

Insurance contract or identification number	14990914
Number of Individuals Covered	0
Insurance policy start date	2018-03-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,121
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $577
Insurance broker organization code?	3

BLUE CROSS AND BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

05913-659*

Policy instance

Insurance contract or identification number	05913-659*
Number of Individuals Covered	0
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,643
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,173
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

90996

Policy instance

Insurance contract or identification number	90996
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,045
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,045
Insurance broker organization code?	3

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	808
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $33,396
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $519,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,396
Insurance broker organization code?	3

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

Policy contract number

730081

Policy instance

Insurance contract or identification number	730081
Number of Individuals Covered	276
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $173,060
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,325,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $173,060
Insurance broker organization code?	3

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

Policy contract number

469881

Policy instance

Insurance contract or identification number	469881
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,750
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	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 $215,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,649
Insurance broker organization code?	3

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	637
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $1,761
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $43,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,761
Insurance broker organization code?	3

CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

M500008

Policy instance

Insurance contract or identification number	M500008
Number of Individuals Covered	236
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	386
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $116
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	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 $47,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $116
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

730081

Policy instance

Insurance contract or identification number	730081
Number of Individuals Covered	641
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $186,239
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,372,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186,239
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	COOL INSURING AGENCY INC.

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	804
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $35,923
Total amount of fees paid to insurance company	USD $9,635
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
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 $542,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,923
Amount paid for insurance broker fees	9635
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ETB12003

Policy instance

Insurance contract or identification number	ETB12003
Number of Individuals Covered	226
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $410
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $410
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	COOL INSURING AGENCY INC.

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

14990914

Policy instance

Insurance contract or identification number	14990914
Number of Individuals Covered	13
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $1,180
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,180
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	COOL INSURING AGENCY

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

05913-659

Policy instance

Insurance contract or identification number	05913-659
Number of Individuals Covered	13
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $1,611
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $49,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,611
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	COOL INSURING AGENCY INC.

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

08423-050

Policy instance

Insurance contract or identification number	08423-050
Number of Individuals Covered	20
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $2,990
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $113,935
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	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

909966

Policy instance

Insurance contract or identification number	909966
Number of Individuals Covered	3
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $2,033
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,033
Insurance broker organization code?	3
Insurance broker name	FIORELLA INSURANCE AGENCY INC

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

90996

Policy instance

Insurance contract or identification number	90996
Number of Individuals Covered	21
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $10,956
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,956
Insurance broker organization code?	3
Insurance broker name	FIORELLA INSURANCE AGENCY INC.

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	225
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $932
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $932
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

730081

Policy instance

Insurance contract or identification number	730081
Number of Individuals Covered	276
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $113,119
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,854,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $113,119
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	611
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $23,715
Total amount of fees paid to insurance company	USD $10,623
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 $329,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,715
Amount paid for insurance broker fees	10623
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )

Policy contract number

D209873

Policy instance

Insurance contract or identification number	D209873
Number of Individuals Covered	636
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,570
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $27,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,570
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

0730081

Policy instance

Insurance contract or identification number	0730081
Number of Individuals Covered	276
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $93,869
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,346,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93,869
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	155
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $735
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $735
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

FLY960104

Policy instance

Insurance contract or identification number	FLY960104
Number of Individuals Covered	446
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $3,694
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC.DEATH & DISMEMB
Welfare Benefit Premiums Paid to Carrier	USD $53,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,694
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

BNK960002

Policy instance

Insurance contract or identification number	BNK960002
Number of Individuals Covered	446
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $4,954
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,954
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	238
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $13,898
Total amount of fees paid to insurance company	USD $8,092
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $198,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,898
Amount paid for insurance broker fees	8092
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

0730081

Policy instance

Insurance contract or identification number	0730081
Number of Individuals Covered	276
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $82,520
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,062,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,520
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	178
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $10,280
Total amount of fees paid to insurance company	USD $7,355
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,280
Amount paid for insurance broker fees	7355
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

BNK960002

Policy instance

Insurance contract or identification number	BNK960002
Number of Individuals Covered	446
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $4,954
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,954
Insurance broker name	COOL INSURING AGENCY INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

FLY960104

Policy instance

Insurance contract or identification number	FLY960104
Number of Individuals Covered	446
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $3,694
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,694
Insurance broker name	COOL INSURING AGENCY INC.

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	128
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $569
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $569
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

BNK960002

Policy instance

Insurance contract or identification number	BNK960002
Number of Individuals Covered	362
Insurance policy start date	2011-08-01
Insurance policy end date	2012-08-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

FLY960104

Policy instance

Insurance contract or identification number	FLY960104
Number of Individuals Covered	362
Insurance policy start date	2011-08-01
Insurance policy end date	2012-08-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2712

Policy instance

Insurance contract or identification number	ST-0100-2712
Number of Individuals Covered	362
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,393
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,393
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

00469881

Policy instance

Insurance contract or identification number	00469881
Number of Individuals Covered	150
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $7,501
Total amount of fees paid to insurance company	USD $2,478
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,501
Amount paid for insurance broker fees	2478
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

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

Policy contract number

0730081

Policy instance

Insurance contract or identification number	0730081
Number of Individuals Covered	276
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $62,748
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,568,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,748
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	97
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $268
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $268
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

884759

Policy instance

Insurance contract or identification number	884759
Number of Individuals Covered	252
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $7,922
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2712

Policy instance

Insurance contract or identification number	ST-0100-2712
Number of Individuals Covered	276
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $1,158
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0730081

Policy instance

Insurance contract or identification number	0730081
Number of Individuals Covered	276
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $53,353
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,333,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720454

Policy instance

Insurance contract or identification number	720454
Number of Individuals Covered	0
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMBLEM HEALTH (National Association of Insurance Commissioners NAIC id number: 55239 )

Policy contract number

46181G737

Policy instance

Insurance contract or identification number	46181G737
Number of Individuals Covered	125
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $4,087,568
Total amount of fees paid to insurance company	USD $112,494,616
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	135266
Additional information about fees paid to insurance broker	BROKER FOR HEALTH INSURANCE
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY, INC.

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Company Name:	MEDICAL DEPOT, INC.
Employer identification number (EIN):	113525013
NAIC Classification:	339110

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2016-02-22
Company Identification Number:	0802397239
Legal Registered Office Address:	99 SEAVIEW BLVD STE 210 PRT WASHINGTN United States of America (USA) 11050