401k Plan data: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES plan

CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 401k Plan overview

Plan Name	CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES
Plan identification number	001

CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

CUSA KBC, LLC has sponsored the creation of one or more 401k plans.

Company Name: CUSA KBC, LLC

Employer identification number (EIN): 200151808

NAIC Classification: 485990

Additional information about CUSA KBC, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 3692566

More information about CUSA KBC, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2014-01-01 BRIAN CEJKA 2014-09-23 CHRIS ARNNETT 2014-09-23
001 2013-01-01 BRIAN CEJKA 2014-07-03
001 2012-01-01 BRIAN CEJKA
001 2011-01-01 RANDY RHODES
001 2009-01-01 RANDY RHODES RANDY RHODES 2010-10-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2014-01-01	BRIAN CEJKA	2014-09-23	CHRIS ARNNETT	2014-09-23
001	2013-01-01	BRIAN CEJKA	2014-07-03
001	2012-01-01	BRIAN CEJKA
001	2011-01-01	RANDY RHODES
001	2009-01-01	RANDY RHODES		RANDY RHODES	2010-10-13

Plan Statistics for CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES

401k plan membership statisitcs for CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES

Measure Date Value
2012: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2012 401k membership
Total participants, beginning-of-year 2012-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 26
Total of all active and inactive participants 2012-01-01 28
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 28
Number of participants with account balances 2012-01-01 27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 2
2011: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2011 401k membership
Total participants, beginning-of-year 2011-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 130
Number of retired or separated participants receiving benefits 2011-01-01 1
Number of other retired or separated participants entitled to future benefits 2011-01-01 19
Total of all active and inactive participants 2011-01-01 150
Total participants 2011-01-01 150
Number of participants with account balances 2011-01-01 68
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 1
2009: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2009 401k membership
Total participants, beginning-of-year 2009-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 144
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 11
Total of all active and inactive participants 2009-01-01 155
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 155
Number of participants with account balances 2009-01-01 82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 4

Measure	Date	Value
2012: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2012 401k membership
Total participants, beginning-of-year	2012-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	26
Total of all active and inactive participants	2012-01-01	28
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	28
Number of participants with account balances	2012-01-01	27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	2
2011: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2011 401k membership
Total participants, beginning-of-year	2011-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	130
Number of retired or separated participants receiving benefits	2011-01-01	1
Number of other retired or separated participants entitled to future benefits	2011-01-01	19
Total of all active and inactive participants	2011-01-01	150
Total participants	2011-01-01	150
Number of participants with account balances	2011-01-01	68
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	1
2009: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2009 401k membership
Total participants, beginning-of-year	2009-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	144
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	11
Total of all active and inactive participants	2009-01-01	155
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	155
Number of participants with account balances	2009-01-01	82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	4

Financial Data on CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES

Measure	Date	Value
2012 : CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$125,194
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$917,951
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$915,175
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$60,551
Value of total assets at end of year	2012-12-31	$315,714
Value of total assets at beginning of year	2012-12-31	$1,108,471
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$2,776
Total interest from all sources	2012-12-31	$563
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2012-12-31	$0
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$45,435
Participant contributions at end of year	2012-12-31	$3,431
Participant contributions at beginning of year	2012-12-31	$52,245
Participant contributions at beginning of year	2012-12-31	$3,625
Other income not declared elsewhere	2012-12-31	$8,182
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$-792,757
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$315,714
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,108,471
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$77,150
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$529,530
Interest on participant loans	2012-12-31	$563
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$235,133
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$521,879
Net investment gain/loss from pooled separate accounts	2012-12-31	$55,898
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$15,116
Employer contributions (assets) at beginning of year	2012-12-31	$1,192
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$915,175
Contract administrator fees	2012-12-31	$2,776
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	FARMER, FUQUA & HUFF, P.C
Accountancy firm EIN	2012-12-31	752599166
2011 : CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$106,588
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$118,754
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$113,167
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$134,192
Value of total assets at end of year	2011-12-31	$1,108,471
Value of total assets at beginning of year	2011-12-31	$1,120,637
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$5,587
Total interest from all sources	2011-12-31	$1,691
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$99,948
Participant contributions at end of year	2011-12-31	$52,245
Participant contributions at beginning of year	2011-12-31	$46,887
Participant contributions at end of year	2011-12-31	$3,625
Participant contributions at beginning of year	2011-12-31	$4,276
Other income not declared elsewhere	2011-12-31	$14,007
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-12,166
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$1,108,471
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,120,637
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in pooled separate accounts at end of year	2011-12-31	$529,530
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$568,419
Interest on participant loans	2011-12-31	$1,691
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$521,879
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$499,603
Net investment gain/loss from pooled separate accounts	2011-12-31	$-43,302
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$34,244
Employer contributions (assets) at end of year	2011-12-31	$1,192
Employer contributions (assets) at beginning of year	2011-12-31	$1,452
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$113,167
Contract administrator fees	2011-12-31	$5,587
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	FARMER, FUQUA & HUFF, P.C.
Accountancy firm EIN	2011-12-31	752599166
2010 : CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$246,955
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$159,044
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$153,788
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$151,632
Value of total assets at end of year	2010-12-31	$1,120,637
Value of total assets at beginning of year	2010-12-31	$1,032,726
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$5,256
Total interest from all sources	2010-12-31	$1,788
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$112,216
Participant contributions at end of year	2010-12-31	$46,887
Participant contributions at beginning of year	2010-12-31	$29,534
Participant contributions at end of year	2010-12-31	$4,276
Participant contributions at beginning of year	2010-12-31	$4,482
Other income not declared elsewhere	2010-12-31	$14,364
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$87,911
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$1,120,637
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$1,032,726
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$568,419
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$521,122
Interest on participant loans	2010-12-31	$1,788
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$499,603
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$476,001
Net investment gain/loss from pooled separate accounts	2010-12-31	$79,171
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$39,416
Employer contributions (assets) at end of year	2010-12-31	$1,452
Employer contributions (assets) at beginning of year	2010-12-31	$1,587
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$153,788
Contract administrator fees	2010-12-31	$5,256
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	FARMER, FUQUA & HUFF, P.C.
Accountancy firm EIN	2010-12-31	752599166
2009 : CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES

2012: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 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	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
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	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2009: CUSA KBC, LLC 401(K) AND SAVINGS PLAN FOR REPRESENTED EMPLOYEES 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
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	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

341376

Policy instance

Insurance contract or identification number	341376
Number of Individuals Covered	28
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,635
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Commission paid to Insurance Broker	USD $644
Insurance broker organization code?	3
Insurance broker name	UBS FINANCIAL SERVICES

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

341376

Policy instance

Insurance contract or identification number	341376
Number of Individuals Covered	150
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,213
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

341376

Policy instance

Insurance contract or identification number	341376
Number of Individuals Covered	182
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,025
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

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Company Name:	CUSA KBC, LLC
Employer identification number (EIN):	200151808
NAIC Classification:	485990

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	3692566