401k Plan data: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA plan

L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 401k Plan overview

Plan Name	L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA
Plan identification number	501

L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental 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

L & J.G. STICKLEY, INC. has sponsored the creation of one or more 401k plans.

Company Name: L & J.G. STICKLEY, INC.

Employer identification number (EIN): 150459630

NAIC Classification: 321900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 IRINA TARASEVICH 2023-06-05 IRINA TARASEVICH
501 2021-01-01 JOHN F. BROGAN 2022-07-22 JOHN F. BROGAN
501 2020-01-01 JOHN F. BROGAN 2021-07-01 JOHN F. BROGAN
501 2019-01-01 JOHN F. BROGAN 2020-06-25 JOHN F. BROGAN
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01 AMINY AUDI
501 2013-01-01 AMINY I. AUDI
501 2012-01-01 AMINY I AUDI
501 2011-01-01 AMINY I AUDI
501 2010-01-01 EDWARD MCCORD
501 2009-01-01 EDWARD MCCORD
501 2007-01-01 EDWARD MCCORD
501 2006-01-01 EDWARD MCCORD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor
501	2022-01-01	IRINA TARASEVICH	2023-06-05	IRINA TARASEVICH
501	2021-01-01	JOHN F. BROGAN	2022-07-22	JOHN F. BROGAN
501	2020-01-01	JOHN F. BROGAN	2021-07-01	JOHN F. BROGAN
501	2019-01-01	JOHN F. BROGAN	2020-06-25	JOHN F. BROGAN
501	2018-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01	AMINY AUDI
501	2013-01-01	AMINY I. AUDI
501	2012-01-01	AMINY I AUDI
501	2011-01-01	AMINY I AUDI
501	2010-01-01	EDWARD MCCORD
501	2009-01-01	EDWARD MCCORD
501	2007-01-01	EDWARD MCCORD
501	2006-01-01	EDWARD MCCORD

Plan Statistics for L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA

401k plan membership statisitcs for L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA

Measure Date Value
2022: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2022 401k membership
Total participants, beginning-of-year 2022-01-01 620
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 389
Total of all active and inactive participants 2022-01-01 389
2021: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2021 401k membership
Total participants, beginning-of-year 2021-01-01 663
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 398
Total of all active and inactive participants 2021-01-01 398
2020: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2020 401k membership
Total participants, beginning-of-year 2020-01-01 729
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 509
Total of all active and inactive participants 2020-01-01 509
2019: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2019 401k membership
Total participants, beginning-of-year 2019-01-01 932
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 698
Total of all active and inactive participants 2019-01-01 698
2018: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2018 401k membership
Total participants, beginning-of-year 2018-01-01 975
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 932
Total of all active and inactive participants 2018-01-01 932
2017: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,159
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 975
Total of all active and inactive participants 2017-01-01 975
2016: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,083
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,159
Total of all active and inactive participants 2016-01-01 1,159
2015: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,158
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,083
Total of all active and inactive participants 2015-01-01 1,083
2014: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,197
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,158
Total of all active and inactive participants 2014-01-01 1,158
2013: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,147
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,197
Total of all active and inactive participants 2013-01-01 1,197
2012: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,179
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,147
Total of all active and inactive participants 2012-01-01 1,147
2011: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,072
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,179
Total of all active and inactive participants 2011-01-01 1,179
2010: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2010 401k membership
Total participants, beginning-of-year 2010-01-01 908
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,072
Total of all active and inactive participants 2010-01-01 1,072
2009: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,004
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 908
Total of all active and inactive participants 2009-01-01 908
2007: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2007 401k membership
Total participants, beginning-of-year 2007-01-01 1,067
Total number of active participants reported on line 7a of the Form 5500 2007-01-01 1,022
Total of all active and inactive participants 2007-01-01 1,022
Total participants 2007-01-01 1,022
2006: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2006 401k membership
Total participants, beginning-of-year 2006-01-01 1,137
Total number of active participants reported on line 7a of the Form 5500 2006-01-01 1,067
Total of all active and inactive participants 2006-01-01 1,067
Total participants 2006-01-01 1,067

Measure	Date	Value
2022: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2022 401k membership
Total participants, beginning-of-year	2022-01-01	620
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	389
Total of all active and inactive participants	2022-01-01	389
2021: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2021 401k membership
Total participants, beginning-of-year	2021-01-01	663
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	398
Total of all active and inactive participants	2021-01-01	398
2020: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2020 401k membership
Total participants, beginning-of-year	2020-01-01	729
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	509
Total of all active and inactive participants	2020-01-01	509
2019: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2019 401k membership
Total participants, beginning-of-year	2019-01-01	932
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	698
Total of all active and inactive participants	2019-01-01	698
2018: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2018 401k membership
Total participants, beginning-of-year	2018-01-01	975
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	932
Total of all active and inactive participants	2018-01-01	932
2017: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,159
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	975
Total of all active and inactive participants	2017-01-01	975
2016: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,083
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,159
Total of all active and inactive participants	2016-01-01	1,159
2015: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,158
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,083
Total of all active and inactive participants	2015-01-01	1,083
2014: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,197
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,158
Total of all active and inactive participants	2014-01-01	1,158
2013: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,147
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,197
Total of all active and inactive participants	2013-01-01	1,197
2012: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,179
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,147
Total of all active and inactive participants	2012-01-01	1,147
2011: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,072
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,179
Total of all active and inactive participants	2011-01-01	1,179
2010: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2010 401k membership
Total participants, beginning-of-year	2010-01-01	908
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,072
Total of all active and inactive participants	2010-01-01	1,072
2009: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,004
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	908
Total of all active and inactive participants	2009-01-01	908
2007: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2007 401k membership
Total participants, beginning-of-year	2007-01-01	1,067
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	1,022
Total of all active and inactive participants	2007-01-01	1,022
Total participants	2007-01-01	1,022
2006: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2006 401k membership
Total participants, beginning-of-year	2006-01-01	1,137
Total number of active participants reported on line 7a of the Form 5500	2006-01-01	1,067
Total of all active and inactive participants	2006-01-01	1,067
Total participants	2006-01-01	1,067

Form 5500 Responses for L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA

2022: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2021: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2020: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2019: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2018: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2017: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2016: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2015: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 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
2014: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	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
2007: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	Yes
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2006: L. & J.G. STICKLEY, INC. CAFETERIA TAX SAVINGS PLA 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	Submission has been amended	Yes
2006-01-01	This submission is the final filing	No
2006-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-01-01	Plan is a collectively bargained plan	No
2006-01-01	Plan funding arrangement – Insurance	Yes
2006-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2006-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

10076886

Policy instance

Insurance contract or identification number	10076886
Number of Individuals Covered	131
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,331
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1331
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

00580531

Policy instance

Insurance contract or identification number	00580531
Number of Individuals Covered	455
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

10150/10151

Policy instance

Insurance contract or identification number	10150/10151
Number of Individuals Covered	389
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,692
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $109,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,692
Insurance broker organization code?	3

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

Policy contract number

10111665

Policy instance

Insurance contract or identification number	10111665
Number of Individuals Covered	510
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $15,036
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $183,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	15036
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

10076885

Policy instance

Insurance contract or identification number	10076885
Number of Individuals Covered	75
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,245
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3245
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

10076886

Policy instance

Insurance contract or identification number	10076886
Number of Individuals Covered	151
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,054
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1054
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

10111665

Policy instance

Insurance contract or identification number	10111665
Number of Individuals Covered	579
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $9,429
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $188,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9429
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

10150/10151

Policy instance

Insurance contract or identification number	10150/10151
Number of Individuals Covered	398
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,598
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $113,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,598
Insurance broker organization code?	3

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

Policy contract number

00580531

Policy instance

Insurance contract or identification number	00580531
Number of Individuals Covered	461
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076885

Policy instance

Insurance contract or identification number	10076885
Number of Individuals Covered	97
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,497
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2497
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

10111665

Policy instance

Insurance contract or identification number	10111665
Number of Individuals Covered	657
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $179,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

10150/10151

Policy instance

Insurance contract or identification number	10150/10151
Number of Individuals Covered	454
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,373
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $116,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,373
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

18670

Policy instance

Insurance contract or identification number	18670
Number of Individuals Covered	524
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076886

Policy instance

Insurance contract or identification number	10076886
Number of Individuals Covered	175
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076885

Policy instance

Insurance contract or identification number	10076885
Number of Individuals Covered	107
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10111665

Policy instance

Insurance contract or identification number	10111665
Number of Individuals Covered	697
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $185,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

18670

Policy instance

Insurance contract or identification number	18670
Number of Individuals Covered	555
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076886

Policy instance

Insurance contract or identification number	10076886
Number of Individuals Covered	176
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076885

Policy instance

Insurance contract or identification number	10076885
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

10150/10151

Policy instance

Insurance contract or identification number	10150/10151
Number of Individuals Covered	468
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,127
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $115,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,127
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

18670

Policy instance

Insurance contract or identification number	18670
Number of Individuals Covered	617
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076886

Policy instance

Insurance contract or identification number	10076886
Number of Individuals Covered	185
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10076885

Policy instance

Insurance contract or identification number	10076885
Number of Individuals Covered	115
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10111665

Policy instance

Insurance contract or identification number	10111665
Number of Individuals Covered	794
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $175,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

10150/10151

Policy instance

Insurance contract or identification number	10150/10151
Number of Individuals Covered	519
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010151

Policy instance

Insurance contract or identification number	00010151
Number of Individuals Covered	410
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	125
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	201
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010150

Policy instance

Insurance contract or identification number	00010150
Number of Individuals Covered	175
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $73,812
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,729
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

18670

Policy instance

Insurance contract or identification number	18670
Number of Individuals Covered	699
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0151091

Policy instance

Insurance contract or identification number	0151091
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,783
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,783
Insurance broker organization code?	3
Insurance broker name	ONEGROUP NY, INC.

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

703767

Policy instance

Insurance contract or identification number	703767
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,721
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,721
Insurance broker organization code?	3
Insurance broker name	ONEGROUP NY, INC.

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	852
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $231,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	205
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,780
Total amount of fees paid to insurance company	USD $124
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,780
Insurance broker organization code?	3
Amount paid for insurance broker fees	124
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010150

Policy instance

Insurance contract or identification number	00010150
Number of Individuals Covered	177
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $69,144
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,144
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

703767

Policy instance

Insurance contract or identification number	703767
Number of Individuals Covered	14
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,370
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,370
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	136
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,514
Total amount of fees paid to insurance company	USD $337
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,514
Insurance broker organization code?	3
Amount paid for insurance broker fees	337
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	962
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,582
Total amount of fees paid to insurance company	USD $1,689
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $241,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,582
Insurance broker organization code?	3
Amount paid for insurance broker fees	1689
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010151

Policy instance

Insurance contract or identification number	00010151
Number of Individuals Covered	522
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,896
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,896
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0151091

Policy instance

Insurance contract or identification number	0151091
Number of Individuals Covered	1655
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $24,121
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $481,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,121
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010150

Policy instance

Insurance contract or identification number	00010150
Number of Individuals Covered	194
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $66,422
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,422
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

703767

Policy instance

Insurance contract or identification number	703767
Number of Individuals Covered	11
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,364
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,364
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	213
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,719
Total amount of fees paid to insurance company	USD $626
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,719
Insurance broker organization code?	3
Amount paid for insurance broker fees	626
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	142
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,246
Total amount of fees paid to insurance company	USD $1,660
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,246
Insurance broker organization code?	3
Amount paid for insurance broker fees	1660
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010151

Policy instance

Insurance contract or identification number	00010151
Number of Individuals Covered	554
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0151091

Policy instance

Insurance contract or identification number	0151091
Number of Individuals Covered	1784
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $43,956
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $490,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,956
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY LLC

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	1033
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,724
Total amount of fees paid to insurance company	USD $9,382
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $225,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9382
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $4,724
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010150

Policy instance

Insurance contract or identification number	00010150
Number of Individuals Covered	190
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $62,208
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,208
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0151091

Policy instance

Insurance contract or identification number	0151091
Number of Individuals Covered	1892
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,368
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $495,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,368
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010151

Policy instance

Insurance contract or identification number	00010151
Number of Individuals Covered	564
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	1089
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,691
Total amount of fees paid to insurance company	USD $7,089
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $220,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7089
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $4,691
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	149
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,953
Total amount of fees paid to insurance company	USD $1,395
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,953
Insurance broker organization code?	3
Amount paid for insurance broker fees	1395
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	218
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,589
Total amount of fees paid to insurance company	USD $559
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,589
Insurance broker organization code?	3
Amount paid for insurance broker fees	559
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

703767

Policy instance

Insurance contract or identification number	703767
Number of Individuals Covered	21
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,045
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,045
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

RV628

Policy instance

Insurance contract or identification number	RV628
Number of Individuals Covered	1056
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,569
Total amount of fees paid to insurance company	USD $11,914
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	11914
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $9,569
Insurance broker name	ENV INSURANCE AGENCY LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

510123

Policy instance

Insurance contract or identification number	510123
Number of Individuals Covered	574
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,849
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,849
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	1051
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,669
Total amount of fees paid to insurance company	USD $7,590
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7590
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $4,669
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	150
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,146
Total amount of fees paid to insurance company	USD $1,533
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,146
Insurance broker organization code?	3
Amount paid for insurance broker fees	1533
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	226
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,764
Total amount of fees paid to insurance company	USD $648
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,764
Insurance broker organization code?	3
Amount paid for insurance broker fees	648
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

703767

Policy instance

Insurance contract or identification number	703767
Number of Individuals Covered	22
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,403
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,403
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00010150

Policy instance

Insurance contract or identification number	00010150
Number of Individuals Covered	191
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $83,556
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,556
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

CLP_ALL_MRP_671

Policy instance

Insurance contract or identification number	CLP_ALL_MRP_671
Number of Individuals Covered	209
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $64,694
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

510123

Policy instance

Insurance contract or identification number	510123
Number of Individuals Covered	615
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,355
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	1094
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,737
Total amount of fees paid to insurance company	USD $10,835
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	148
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,291
Total amount of fees paid to insurance company	USD $2,087
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

X0181

Policy instance

Insurance contract or identification number	X0181
Number of Individuals Covered	11
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	250
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,917
Total amount of fees paid to insurance company	USD $927
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

RV628

Policy instance

Insurance contract or identification number	RV628
Number of Individuals Covered	1093
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,914
Total amount of fees paid to insurance company	USD $12,128
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

RV628

Policy instance

Insurance contract or identification number	RV628
Number of Individuals Covered	1075
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,817
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,817
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY LLC

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

Policy contract number

000010111665

Policy instance

Insurance contract or identification number	000010111665
Number of Individuals Covered	1077
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,660
Total amount of fees paid to insurance company	USD $4,837
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4837
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $4,660
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

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

Policy contract number

000010076885

Policy instance

Insurance contract or identification number	000010076885
Number of Individuals Covered	144
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,087
Total amount of fees paid to insurance company	USD $1,104
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,087
Insurance broker organization code?	3
Amount paid for insurance broker fees	1104
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN, INC.

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

Policy contract number

000010076886

Policy instance

Insurance contract or identification number	000010076886
Number of Individuals Covered	237
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,858
Total amount of fees paid to insurance company	USD $534
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,858
Insurance broker organization code?	3
Amount paid for insurance broker fees	534
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN, INC.

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

SLC889

Policy instance

Insurance contract or identification number	SLC889
Number of Individuals Covered	637
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,190
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,190
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

X0181

Policy instance

Insurance contract or identification number	X0181
Number of Individuals Covered	12
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

CLP_ALL_MRP_671

Policy instance

Insurance contract or identification number	CLP_ALL_MRP_671
Number of Individuals Covered	329
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $63,808
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,808
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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Company Name:	L & J.G. STICKLEY, INC.
Employer identification number (EIN):	150459630
NAIC Classification:	321900