401k Plan data: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN plan

GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Temporary disability (accident and sickness)
Long-term disability cover
Other welfare benefit cover
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

GREENE GROUP INDUSTRIES has sponsored the creation of one or more 401k plans.

Company Name: GREENE GROUP INDUSTRIES

Employer identification number (EIN): 201651857

NAIC Classification: 332900

Additional information about GREENE GROUP INDUSTRIES

Jurisdiction of Incorporation: Michigan Department of Licensing & Regulatory Affairs

Incorporation Date:

Company Identification Number: B9164M

More information about GREENE GROUP INDUSTRIES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2019-01-01 SHELLY LOJUK 2020-08-19
501 2019-01-01
501 2018-01-01
501 2017-06-01
501 2016-06-01
501 2015-06-01 JILL MCDOUGAL JILL MCDOUGAL 2017-01-26

Plan Statistics for GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 116
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 117
2019: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 108
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 108
2018: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 121
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 121
2017: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 112
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 110
Total of all active and inactive participants 2017-06-01 110
2016: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 107
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 112
Total of all active and inactive participants 2016-06-01 112
2015: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 101
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 107
Number of retired or separated participants receiving benefits 2015-06-01 0
Number of other retired or separated participants entitled to future benefits 2015-06-01 0
Total of all active and inactive participants 2015-06-01 107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-06-01 0
Total participants 2015-06-01 107

Measure	Date	Value
2022: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	116
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	117
2019: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	108
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	108
2018: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	121
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	121
2017: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	112
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	110
Total of all active and inactive participants	2017-06-01	110
2016: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	107
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	112
Total of all active and inactive participants	2016-06-01	112
2015: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	101
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	107
Number of retired or separated participants receiving benefits	2015-06-01	0
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-06-01	0
Total participants	2015-06-01	107

Form 5500 Responses for GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN

2022: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: GREENE MANUFACTURING TECHNOLOGIES EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	First time form 5500 has been submitted	Yes
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	No
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

6166

Policy instance

Insurance contract or identification number	6166
Number of Individuals Covered	172
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,523
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $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 $9,523
Insurance broker organization code?	3

TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

156042

Policy instance

Insurance contract or identification number	156042
Number of Individuals Covered	97
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMEDICINE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )

Policy contract number

10004950

Policy instance

Insurance contract or identification number	10004950
Number of Individuals Covered	88
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $22,325
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $524,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,769
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10004949

Policy instance

Insurance contract or identification number	10004949
Number of Individuals Covered	78
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,324
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $346,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,217
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10113901001

Policy instance

Insurance contract or identification number	10113901001
Number of Individuals Covered	165
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $946
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $946
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6DN

Policy instance

Insurance contract or identification number	GLUG0B6DN
Number of Individuals Covered	116
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $316
Total amount of fees paid to insurance company	USD $564
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	564
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $316

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6DN

Policy instance

Insurance contract or identification number	GVTL0B6DN
Number of Individuals Covered	65
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,681
Total amount of fees paid to insurance company	USD $564
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $31,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,681
Insurance broker organization code?	3
Amount paid for insurance broker fees	564
Additional information about fees paid to insurance broker	FEES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0B6DN

Policy instance

Insurance contract or identification number	GUPR0B6DN
Number of Individuals Covered	45
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,668
Total amount of fees paid to insurance company	USD $558
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,668
Insurance broker organization code?	3
Amount paid for insurance broker fees	558
Additional information about fees paid to insurance broker	FEES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC 0B6DN

Policy instance

Insurance contract or identification number	GUC 0B6DN
Number of Individuals Covered	59
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,446
Total amount of fees paid to insurance company	USD $432
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,446
Insurance broker organization code?	3
Amount paid for insurance broker fees	432
Additional information about fees paid to insurance broker	FEES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6DN

Policy instance

Insurance contract or identification number	GUDH0B6DN
Number of Individuals Covered	22
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $740
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $740
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0006166

Policy instance

Insurance contract or identification number	0006166
Number of Individuals Covered	198
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,856
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,856
Insurance broker organization code?	3

ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )

Policy contract number

10004950

Policy instance

Insurance contract or identification number	10004950
Number of Individuals Covered	122
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $18,752
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,752
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10004949

Policy instance

Insurance contract or identification number	10004949
Number of Individuals Covered	65
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,550
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,550
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0B6DN

Policy instance

Insurance contract or identification number	GUDE0B6DN
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $556
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $556
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10113901001

Policy instance

Insurance contract or identification number	10113901001
Number of Individuals Covered	186
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,019
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,019
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6DN

Policy instance

Insurance contract or identification number	GLUG0B6DN
Number of Individuals Covered	125
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,027
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,027
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6DN

Policy instance

Insurance contract or identification number	GVTL0B6DN
Number of Individuals Covered	63
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,582
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0B6DN

Policy instance

Insurance contract or identification number	GUPR0B6DN
Number of Individuals Covered	51
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,630
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,630
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0B6DN

Policy instance

Insurance contract or identification number	GUC0B6DN
Number of Individuals Covered	53
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,583
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,583
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0006166

Policy instance

Insurance contract or identification number	0006166
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 $6,153
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,479
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0B6DN

Policy instance

Insurance contract or identification number	GUDE0B6DN
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $617
Total amount of fees paid to insurance company	USD $74
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $351
Insurance broker organization code?	3
Amount paid for insurance broker fees	74
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6DN

Policy instance

Insurance contract or identification number	GUDH0B6DN
Number of Individuals Covered	10
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $275
Total amount of fees paid to insurance company	USD $54
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112
Amount paid for insurance broker fees	54
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0B6DN

Policy instance

Insurance contract or identification number	GUC0B6DN
Number of Individuals Covered	59
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,033
Total amount of fees paid to insurance company	USD $721
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,143
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0B6DN

Policy instance

Insurance contract or identification number	GUPR0B6DN
Number of Individuals Covered	50
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,451
Total amount of fees paid to insurance company	USD $824
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,424
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10004949

Policy instance

Insurance contract or identification number	10004949
Number of Individuals Covered	54
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,312
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $191,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,766
Insurance broker organization code?	3

ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )

Policy contract number

10004950

Policy instance

Insurance contract or identification number	10004950
Number of Individuals Covered	123
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $21,986
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $637,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,328
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10113901001

Policy instance

Insurance contract or identification number	10113901001
Number of Individuals Covered	171
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $950
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $536
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6DN

Policy instance

Insurance contract or identification number	GLUG0B6DN
Number of Individuals Covered	121
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $330
Total amount of fees paid to insurance company	USD $433
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $195
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6DN

Policy instance

Insurance contract or identification number	GVTL0B6DN
Number of Individuals Covered	59
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,264
Total amount of fees paid to insurance company	USD $762
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,818
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10004949

Policy instance

Insurance contract or identification number	10004949
Number of Individuals Covered	40
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,981
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $111,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,981
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 )

Policy contract number

10004950

Policy instance

Insurance contract or identification number	10004950
Number of Individuals Covered	129
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $22,152
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $422,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,152
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0006166

Policy instance

Insurance contract or identification number	0006166
Number of Individuals Covered	188
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,759
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 $3,759
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10113901001

Policy instance

Insurance contract or identification number	10113901001
Number of Individuals Covered	187
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $533
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $533
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6DN

Policy instance

Insurance contract or identification number	GLUG0B6DN
Number of Individuals Covered	112
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $190
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $190
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6DN

Policy instance

Insurance contract or identification number	GVTL0B6DN
Number of Individuals Covered	70
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,145
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,145
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0B6DN

Policy instance

Insurance contract or identification number	GUPR0B6DN
Number of Individuals Covered	47
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,405
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,405
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC0B6DN

Policy instance

Insurance contract or identification number	GUC0B6DN
Number of Individuals Covered	63
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,296
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,296
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6DN

Policy instance

Insurance contract or identification number	GUDH0B6DN
Number of Individuals Covered	19
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $424
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $424
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0B6DN

Policy instance

Insurance contract or identification number	GUDE0B6DN
Number of Individuals Covered	15
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $209
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Insurance broker organization code?	3
Insurance broker name	TIMBERLAND GROUP SERVICES INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752985

Policy instance

Insurance contract or identification number	752985
Number of Individuals Covered	107
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $1,669
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,343
Amount paid for insurance broker fees	326
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILSHIRE BENEFITS GROUP INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752985

Policy instance

Insurance contract or identification number	752985
Number of Individuals Covered	21
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $1,909
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,626
Amount paid for insurance broker fees	283
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILSHIRE BENEFITS GROUP

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00279747

Policy instance

Insurance contract or identification number	00279747
Number of Individuals Covered	90
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	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
Welfare Benefit Premiums Paid to Carrier	USD $689,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752985

Policy instance

Insurance contract or identification number	752985
Number of Individuals Covered	33
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $1,875
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,484
Amount paid for insurance broker fees	391
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILSHIRE BENEFITS GROUP INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752985

Policy instance

Insurance contract or identification number	752985
Number of Individuals Covered	100
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $2,412
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $50,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,784
Amount paid for insurance broker fees	628
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILSHIRE BENEFITS GROUP INC.

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Company Name:	GREENE GROUP INDUSTRIES
Employer identification number (EIN):	201651857
NAIC Classification:	332900

Jurisdiction of Incorporation:	Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number:	B9164M

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2019-01-01	SHELLY LOJUK	2020-08-19
501	2019-01-01
501	2018-01-01
501	2017-06-01
501	2016-06-01
501	2015-06-01	JILL MCDOUGAL		JILL MCDOUGAL	2017-01-26