401k Plan data: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN plan

KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN
Plan identification number	501

KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE 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

KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. has sponsored the creation of one or more 401k plans.

Company Name: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC.

Employer identification number (EIN): 131921089

NAIC Classification: 424990
NAIC Description: Other Miscellaneous Nondurable Goods Merchant Wholesalers

Additional information about KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1959-04-24

Company Identification Number: 119126

Legal Registered Office Address: 80 STATE STREET
New York
ALBANY
United States of America (USA)
12207

More information about KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 BRIAN CUPKA
501 2016-01-01 BRIAN CUPKA
501 2015-01-01 BRIAN CUPKA
501 2014-01-01 BRIAN CUPKA
501 2014-01-01 BRIAN CUPKA
501 2013-01-01 BRIAN CUPKA
501 2012-01-01 DONALD J. WARWICK
501 2011-01-01 DONALD J. WARWICK
501 2009-01-01 DONALD J. WARWICK
501 2009-01-01 DONALD J. WARWICK 2010-07-22

Plan Statistics for KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN

Measure Date Value
2023: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 5,331
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 5,316
Number of retired or separated participants receiving benefits 2023-01-01 146
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 5,462
2022: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 6,308
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 5,187
Number of retired or separated participants receiving benefits 2022-01-01 144
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 5,331
2021: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 6,725
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 6,192
Number of retired or separated participants receiving benefits 2021-01-01 116
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 6,308
2020: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 6,616
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 6,567
Number of retired or separated participants receiving benefits 2020-01-01 158
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 6,725
2019: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 6,738
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 6,567
Number of retired or separated participants receiving benefits 2019-01-01 49
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 6,616
2018: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 6,920
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 6,686
Number of retired or separated participants receiving benefits 2018-01-01 52
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 6,738
2017: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 7,051
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 6,764
Number of retired or separated participants receiving benefits 2017-01-01 156
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 6,920
2016: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 6,813
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 6,891
Number of retired or separated participants receiving benefits 2016-01-01 160
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 7,051
2015: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 6,686
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 6,813
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 6,813
2014: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 5,660
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 5,807
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 5,575
Number of retired or separated participants receiving benefits 2013-01-01 85
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 5,660
2012: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 5,106
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 5,673
Number of retired or separated participants receiving benefits 2012-01-01 171
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 5,844
2011: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 4,888
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 4,980
Number of retired or separated participants receiving benefits 2011-01-01 126
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 5,106
2009: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 3,864
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 4,692
Number of retired or separated participants receiving benefits 2009-01-01 231
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 4,923

Measure	Date	Value
2023: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	5,331
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	5,316
Number of retired or separated participants receiving benefits	2023-01-01	146
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	5,462
2022: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	6,308
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	5,187
Number of retired or separated participants receiving benefits	2022-01-01	144
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	5,331
2021: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	6,725
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	6,192
Number of retired or separated participants receiving benefits	2021-01-01	116
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	6,308
2020: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	6,616
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	6,567
Number of retired or separated participants receiving benefits	2020-01-01	158
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	6,725
2019: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	6,738
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	6,567
Number of retired or separated participants receiving benefits	2019-01-01	49
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	6,616
2018: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	6,920
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	6,686
Number of retired or separated participants receiving benefits	2018-01-01	52
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	6,738
2017: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	7,051
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	6,764
Number of retired or separated participants receiving benefits	2017-01-01	156
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	6,920
2016: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	6,813
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	6,891
Number of retired or separated participants receiving benefits	2016-01-01	160
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	7,051
2015: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	6,686
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	6,813
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	6,813
2014: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	5,660
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	5,807
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	5,575
Number of retired or separated participants receiving benefits	2013-01-01	85
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	5,660
2012: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	5,106
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	5,673
Number of retired or separated participants receiving benefits	2012-01-01	171
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	5,844
2011: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	4,888
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	4,980
Number of retired or separated participants receiving benefits	2011-01-01	126
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	5,106
2009: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	3,864
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	4,692
Number of retired or separated participants receiving benefits	2009-01-01	231
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	4,923

Form 5500 Responses for KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN

2023: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
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: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	This submission is the final filing	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC. HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

SA2-890LF065301

Policy instance

Insurance contract or identification number	SA2-890LF065301
Number of Individuals Covered	5316
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $106,732
Total amount of fees paid to insurance company	USD $106,523
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,303,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

GF2-890LF065301

Policy instance

Insurance contract or identification number	GF2-890LF065301
Number of Individuals Covered	5356
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of fees paid to insurance company	USD $47,550
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,212,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	559
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of fees paid to insurance company	USD $33,540
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $90,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 3086 )

Policy contract number

UNI-203145

Policy instance

Insurance contract or identification number	UNI-203145
Number of Individuals Covered	4036
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $88,026
Welfare Benefit Premiums Paid to Carrier	USD $1,760,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

CI 960762

Policy instance

Insurance contract or identification number	CI 960762
Number of Individuals Covered	1675
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $103,195
Total amount of fees paid to insurance company	USD $25,799
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $478,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	46
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,806
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

HC960276

Policy instance

Insurance contract or identification number	HC960276
Number of Individuals Covered	1247
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $57,065
Total amount of fees paid to insurance company	USD $14,266
Other welfare benefits provided	VOLUNTARY HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $264,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

AI 960788

Policy instance

Insurance contract or identification number	AI 960788
Number of Individuals Covered	1398
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $61,917
Total amount of fees paid to insurance company	USD $15,479
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $286,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N18154298

Policy instance

Insurance contract or identification number	N18154298
Number of Individuals Covered	5065
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of fees paid to insurance company	USD $150
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 )

Policy contract number

9905856

Policy instance

Insurance contract or identification number	9905856
Number of Individuals Covered	504
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $9,396
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $90,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

GF2-890LF065301

Policy instance

Insurance contract or identification number	GF2-890LF065301
Number of Individuals Covered	5179
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $109,700
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,317,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	39850
Additional information about fees paid to insurance broker	OTHERS
Insurance broker organization code?	3

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	572
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $25,266
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $107,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	25266
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

SA2-890LF065301

Policy instance

Insurance contract or identification number	SA2-890LF065301
Number of Individuals Covered	5187
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $99,607
Total amount of fees paid to insurance company	USD $195,474
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,498,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $99,607
Insurance broker organization code?	3
Amount paid for insurance broker fees	67737
Additional information about fees paid to insurance broker	OTHERS

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

Policy contract number

CI 960762

Policy instance

Insurance contract or identification number	CI 960762
Number of Individuals Covered	1605
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $90,730
Total amount of fees paid to insurance company	USD $31,944
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $454,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90,730
Amount paid for insurance broker fees	9262
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,510
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,009
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

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335316

Policy instance

Insurance contract or identification number	0010335316
Number of Individuals Covered	647
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $27,036
Total amount of fees paid to insurance company	USD $4,474
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $225,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,769
Amount paid for insurance broker fees	3882
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

HC960276

Policy instance

Insurance contract or identification number	HC960276
Number of Individuals Covered	1174
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $50,402
Total amount of fees paid to insurance company	USD $18,229
Other welfare benefits provided	VOLUNTARY HOSPITAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $252,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,402
Amount paid for insurance broker fees	5629
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

AI 960788

Policy instance

Insurance contract or identification number	AI 960788
Number of Individuals Covered	1327
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $56,017
Total amount of fees paid to insurance company	USD $19,530
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $280,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,017
Amount paid for insurance broker fees	5526
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0002370

Policy instance

Insurance contract or identification number	W0002370
Number of Individuals Covered	89
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $7
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $913,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7
Additional information about fees paid to insurance broker	MISC. GIFTS, MEALS & ENTERTAINMENT ALLOCATION
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N18154298

Policy instance

Insurance contract or identification number	N18154298
Number of Individuals Covered	5065
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $268
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	268
Additional information about fees paid to insurance broker	CONTINGENT COMMISSION
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

9905856

Policy instance

Insurance contract or identification number	9905856
Number of Individuals Covered	273
Insurance policy start date	2022-09-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,677
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $9,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,677
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADDN18154298

Policy instance

Insurance contract or identification number	ADDN18154298
Number of Individuals Covered	6000
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	6192
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,471,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	671
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $35,000
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $128,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	35000
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	2655
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $17,503
Total amount of fees paid to insurance company	USD $636
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $137,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,733
Insurance broker organization code?	3
Amount paid for insurance broker fees	636
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR FEES

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	5348
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $47,632
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,720,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,632
Insurance broker organization code?	3

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	42
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,662
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,184
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335316

Policy instance

Insurance contract or identification number	0010335316
Number of Individuals Covered	609
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $23,448
Total amount of fees paid to insurance company	USD $2,479
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $220,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,770
Amount paid for insurance broker fees	2127
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

HC960276

Policy instance

Insurance contract or identification number	HC960276
Number of Individuals Covered	1153
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $51,781
Total amount of fees paid to insurance company	USD $17,070
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,781
Amount paid for insurance broker fees	4125
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

AI 960788

Policy instance

Insurance contract or identification number	AI 960788
Number of Individuals Covered	1295
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $51,072
Total amount of fees paid to insurance company	USD $17,418
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $277,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,072
Amount paid for insurance broker fees	4650
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

FML985104

Policy instance

Insurance contract or identification number	FML985104
Number of Individuals Covered	5292
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	FMLA
Welfare Benefit Premiums Paid to Carrier	USD $91,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0002370

Policy instance

Insurance contract or identification number	W0002370
Number of Individuals Covered	98
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,045,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

CI 960762

Policy instance

Insurance contract or identification number	CI 960762
Number of Individuals Covered	1597
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $82,633
Total amount of fees paid to insurance company	USD $27,685
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $449,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,633
Amount paid for insurance broker fees	7027
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

CI 960762

Policy instance

Insurance contract or identification number	CI 960762
Number of Individuals Covered	1574
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $86,622
Total amount of fees paid to insurance company	USD $14,398
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $433,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86,622
Amount paid for insurance broker fees	2199
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	43
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,214
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,489
Insurance broker organization code?	3

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	6567
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $100,000
Total amount of fees paid to insurance company	USD $5,000
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,587,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $100,000
Amount paid for insurance broker fees	5000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	884
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $150,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	3028
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $22,442
Total amount of fees paid to insurance company	USD $766
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $183,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,325
Insurance broker organization code?	3
Amount paid for insurance broker fees	635
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR FEES

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	5358
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $34,292
Total amount of fees paid to insurance company	USD $5,000
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,143,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,292
Amount paid for insurance broker fees	5000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335316

Policy instance

Insurance contract or identification number	0010335316
Number of Individuals Covered	666
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $25,868
Total amount of fees paid to insurance company	USD $4,597
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $243,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,224
Amount paid for insurance broker fees	4014
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

242324

Policy instance

Insurance contract or identification number	242324
Number of Individuals Covered	5773
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $115,424
Welfare Benefit Premiums Paid to Carrier	USD $2,547,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $115,424
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N18154298

Policy instance

Insurance contract or identification number	N18154298
Number of Individuals Covered	6000
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0002370

Policy instance

Insurance contract or identification number	W0002370
Number of Individuals Covered	120
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $1,408
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,099,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1408
Additional information about fees paid to insurance broker	SERVICE FEES BONUS OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FML985104

Policy instance

Insurance contract or identification number	FML985104
Number of Individuals Covered	5931
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	FMLA
Welfare Benefit Premiums Paid to Carrier	USD $169,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

AI 960788

Policy instance

Insurance contract or identification number	AI 960788
Number of Individuals Covered	1368
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $57,290
Total amount of fees paid to insurance company	USD $15,764
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $286,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,290
Amount paid for insurance broker fees	1431
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

539133

Policy instance

Insurance contract or identification number	539133
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $401
Other welfare benefits provided	LTC
Welfare Benefit Premiums Paid to Carrier	USD $3,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $401
Insurance broker organization code?	3

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

Policy contract number

HC960276

Policy instance

Insurance contract or identification number	HC960276
Number of Individuals Covered	1165
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $63,674
Total amount of fees paid to insurance company	USD $1,176
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $254,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,939
Amount paid for insurance broker fees	1176
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

CI 960762

Policy instance

Insurance contract or identification number	CI 960762
Number of Individuals Covered	1632
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $85,641
Total amount of fees paid to insurance company	USD $51,211
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $428,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,641
Amount paid for insurance broker fees	22295
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	49
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,385
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,532
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335316

Policy instance

Insurance contract or identification number	0010335316
Number of Individuals Covered	740
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $31,519
Total amount of fees paid to insurance company	USD $6,123
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $286,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,884
Amount paid for insurance broker fees	4818
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

242324

Policy instance

Insurance contract or identification number	242324
Number of Individuals Covered	5192
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $118,535
Total amount of fees paid to insurance company	USD $24,054
Welfare Benefit Premiums Paid to Carrier	USD $2,370,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118,535
Amount paid for insurance broker fees	24054
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

HC960276

Policy instance

Insurance contract or identification number	HC960276
Number of Individuals Covered	1148
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $46,415
Total amount of fees paid to insurance company	USD $27,352
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $232,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,415
Amount paid for insurance broker fees	11762
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

539133

Policy instance

Insurance contract or identification number	539133
Number of Individuals Covered	30
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,098
Other welfare benefits provided	LTC
Welfare Benefit Premiums Paid to Carrier	USD $20,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,098
Insurance broker organization code?	3

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

Policy contract number

AI 960788

Policy instance

Insurance contract or identification number	AI 960788
Number of Individuals Covered	1414
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $58,806
Total amount of fees paid to insurance company	USD $35,033
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $294,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,806
Amount paid for insurance broker fees	15207
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FML985104

Policy instance

Insurance contract or identification number	FML985104
Number of Individuals Covered	6578
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	FMLA
Welfare Benefit Premiums Paid to Carrier	USD $164,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	7709
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $108,333
Total amount of fees paid to insurance company	USD $15,000
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,666,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108,333
Amount paid for insurance broker fees	15000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	1056
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $189,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	6920
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $24,400
Total amount of fees paid to insurance company	USD $1,709
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTA AND VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $210,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,055
Insurance broker organization code?	3
Amount paid for insurance broker fees	1709
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	6636
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $33,970
Total amount of fees paid to insurance company	USD $15,000
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,132,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,970
Amount paid for insurance broker fees	15000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	6740
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $37,194
Total amount of fees paid to insurance company	USD $17,500
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,239,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,194
Amount paid for insurance broker fees	17500
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	6920
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $28,448
Total amount of fees paid to insurance company	USD $1,606
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTA AND VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $228,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,802
Insurance broker organization code?	3
Amount paid for insurance broker fees	1606
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	1152
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $207,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	7950
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $91,667
Total amount of fees paid to insurance company	USD $17,500
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,358,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,667
Amount paid for insurance broker fees	17500
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850838

Policy instance

Insurance contract or identification number	850838
Number of Individuals Covered	737
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $47,728
Total amount of fees paid to insurance company	USD $8,240
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,815
Amount paid for insurance broker fees	4217
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	50
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,490
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,245
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335136

Policy instance

Insurance contract or identification number	0010335136
Number of Individuals Covered	719
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $42,109
Total amount of fees paid to insurance company	USD $3,195
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $281,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,064
Amount paid for insurance broker fees	1642
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

242324

Policy instance

Insurance contract or identification number	242324
Number of Individuals Covered	5392
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $112,483
Total amount of fees paid to insurance company	USD $33,750
Welfare Benefit Premiums Paid to Carrier	USD $2,249,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112,483
Amount paid for insurance broker fees	33750
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

PREMERA BLUE CROSS BLUE SHIELD OF ALASKA, INC. (National Association of Insurance Commissioners NAIC id number: 11677 )

Policy contract number

1028797

Policy instance

Insurance contract or identification number	1028797
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,839
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,839
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

539133

Policy instance

Insurance contract or identification number	539133
Number of Individuals Covered	8
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,531
Other welfare benefits provided	LTC
Welfare Benefit Premiums Paid to Carrier	USD $22,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,531
Insurance broker organization code?	3

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	6764
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $40,519
Total amount of fees paid to insurance company	USD $17,500
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,350,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,519
Amount paid for insurance broker fees	17500
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	6920
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $26,375
Total amount of fees paid to insurance company	USD $1,751
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTA AND VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $239,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,925
Insurance broker organization code?	3
Amount paid for insurance broker fees	1751
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	1310
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $227,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	8046
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $100,000
Total amount of fees paid to insurance company	USD $17,500
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,677,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $100,000
Amount paid for insurance broker fees	17500
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850838

Policy instance

Insurance contract or identification number	850838
Number of Individuals Covered	693
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $93,114
Total amount of fees paid to insurance company	USD $13,416
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $344,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,568
Amount paid for insurance broker fees	6708
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	BCINSOURCING LLC

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

Policy contract number

R0558304

Policy instance

Insurance contract or identification number	R0558304
Number of Individuals Covered	49
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,398
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,199
Insurance broker organization code?	3
Insurance broker name	BCINSOURCING, LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010335136

Policy instance

Insurance contract or identification number	0010335136
Number of Individuals Covered	693
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $62,744
Total amount of fees paid to insurance company	USD $2,957
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $264,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,372
Amount paid for insurance broker fees	1734
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

PREMERA BLUE CROSS BLUE SHIELD OF ALASKA, INC. (National Association of Insurance Commissioners NAIC id number: 11677 )

Policy contract number

1028797

Policy instance

Insurance contract or identification number	1028797
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,731
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $234,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,731
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

242324

Policy instance

Insurance contract or identification number	242324
Number of Individuals Covered	5547
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $151,668
Welfare Benefit Premiums Paid to Carrier	USD $2,359,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	117918
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

850838

Policy instance

Insurance contract or identification number	850838
Number of Individuals Covered	355
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $89,566
Total amount of fees paid to insurance company	USD $205
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,041
Amount paid for insurance broker fees	181
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THEODORE F. VAN DORN

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

Policy contract number

FLX980357

Policy instance

Insurance contract or identification number	FLX980357
Number of Individuals Covered	6946
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $100,000
Total amount of fees paid to insurance company	USD $40,000
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,118,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $100,000
Amount paid for insurance broker fees	40000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	13087
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $2,307,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	5617
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $35,895
Total amount of fees paid to insurance company	USD $20,000
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,196,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,895
Amount paid for insurance broker fees	20000
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

0877115

Policy instance

Insurance contract or identification number	0877115
Number of Individuals Covered	778
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $206,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0010335316

Policy instance

Insurance contract or identification number	0010335316
Number of Individuals Covered	55
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $21,864
Other welfare benefits provided	WHOLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $24,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,932
Insurance broker organization code?	3
Insurance broker name	HEALTH & BENEFIT SYSTEMS, INC.

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	4355
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $27,482
Total amount of fees paid to insurance company	USD $1,974
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTA AND AD&D
Welfare Benefit Premiums Paid to Carrier	USD $265,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,600
Insurance broker organization code?	3
Amount paid for insurance broker fees	1974
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	7500
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREPAID DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $1,618,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	4780
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $45,249
Total amount of fees paid to insurance company	USD $17,500
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,508,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,249
Amount paid for insurance broker fees	17500
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	5483
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $24,533
Total amount of fees paid to insurance company	USD $2,132
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTA AND AD&D
Welfare Benefit Premiums Paid to Carrier	USD $236,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,661
Insurance broker organization code?	3
Amount paid for insurance broker fees	2132
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

NYD074773

Policy instance

Insurance contract or identification number	NYD074773
Number of Individuals Covered	404
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $349
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $22,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	349
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

SDJ980042

Policy instance

Insurance contract or identification number	SDJ980042
Number of Individuals Covered	565
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $1,536
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $104,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1536
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

PHYSICIANS PLUS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95341 )

Policy contract number

P58750

Policy instance

Insurance contract or identification number	P58750
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,655
Total amount of fees paid to insurance company	USD $250
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,161
Amount paid for insurance broker fees	250
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

643092

Policy instance

Insurance contract or identification number	643092
Number of Individuals Covered	2406
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Welfare Benefit Premiums Paid to Carrier	USD $836,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

0877115

Policy instance

Insurance contract or identification number	0877115
Number of Individuals Covered	741
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $211,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	5286
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $23,521
Total amount of fees paid to insurance company	USD $2,903
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND 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 $235,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,521
Amount paid for insurance broker fees	1000
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	4856
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $30,893
Total amount of fees paid to insurance company	USD $15,588
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,029,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,893
Amount paid for insurance broker fees	15588
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

0877115

Policy instance

Insurance contract or identification number	0877115
Number of Individuals Covered	809
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,738
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $223,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,738
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	7274
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $511,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

67826-1

Policy instance

Insurance contract or identification number	67826-1
Number of Individuals Covered	11630
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $56,959
Total amount of fees paid to insurance company	USD $77,036
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,898,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,959
Amount paid for insurance broker fees	77036
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

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

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	2053
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $544,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	841
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,003,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	3834
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,171
Total amount of fees paid to insurance company	USD $1,889
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND 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 $228,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,171
Insurance broker organization code?	3
Amount paid for insurance broker fees	1889
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	5030
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $20,057
Total amount of fees paid to insurance company	USD $20,658
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,318,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	20658
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $20,057
Insurance broker name	LOCKTON COMPANIES LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

877115

Policy instance

Insurance contract or identification number	877115
Number of Individuals Covered	9690
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $23,267
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,165,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,267
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

877115

Policy instance

Insurance contract or identification number	877115
Number of Individuals Covered	8904
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $47,538
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,917,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	4567
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,642
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,181,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	809
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,098,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	3524
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $19,264
Total amount of fees paid to insurance company	USD $1,861
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND 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 $208,343
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

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	1975
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $507,125
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

3209868

Policy instance

Insurance contract or identification number	3209868
Number of Individuals Covered	2998
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,426,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

42445

Policy instance

Insurance contract or identification number	42445
Number of Individuals Covered	3434
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $23,409
Total amount of fees paid to insurance company	USD $1,846
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND 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 $234,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,409
Insurance broker organization code?	3
Amount paid for insurance broker fees	1846
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

877115

Policy instance

Insurance contract or identification number	877115
Number of Individuals Covered	8948
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53,073
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,914,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,073
Insurance broker organization code?	3
Insurance broker name	KINLOCH CONSULTING GROUP INC.

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

Policy contract number

FLK980072

Policy instance

Insurance contract or identification number	FLK980072
Number of Individuals Covered	4571
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $32,004
Total amount of fees paid to insurance company	USD $43,155
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,066,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,004
Amount paid for insurance broker fees	43155
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KINLOCH CONSULTING GROUP

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Company Name:	KONICA MINOLTA BUSINESS SOLUTIONS U.S.A., INC.
Employer identification number (EIN):	131921089
NAIC Classification:	424990
NAIC Description:	Other Miscellaneous Nondurable Goods Merchant Wholesalers

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1959-04-24
Company Identification Number:	119126
Legal Registered Office Address:	80 STATE STREET New York ALBANY United States of America (USA) 12207