401k Plan data: RBA, INC. HEALTH & WELFARE PLAN plan

RBA, INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	RBA, INC. HEALTH & WELFARE PLAN
Plan identification number	501

RBA, INC. HEALTH & WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

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

Company Name: RBA, INC.

Employer identification number (EIN): 204004667

NAIC Classification: 541511
NAIC Description: Custom Computer Programming Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RBA, INC. HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 BRITTNIE HOMSTAD BRITTNIE HOMSTAD 2018-07-17
501 2016-01-01 BRITTNIE HOMSTAD BRITTNIE HOMSTAD 2017-07-06
501 2015-01-01 KAREN BROS KAREN BROS 2016-07-21
501 2014-01-01 KAREN BROS KAREN BROS 2015-07-29
501 2014-01-01 KAREN BROS KAREN BROS 2015-07-22
501 2013-01-01 KAREN BROS KAREN BROS 2014-10-14
501 2012-01-01 KAREN BROS KAREN BROS 2013-10-15
501 2011-01-01 MICHAEL FITZGIBBONS MICHAEL FITZGIBBONS 2012-10-12

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	BRITTNIE HOMSTAD	BRITTNIE HOMSTAD	2018-07-17
501	2016-01-01	BRITTNIE HOMSTAD	BRITTNIE HOMSTAD	2017-07-06
501	2015-01-01	KAREN BROS	KAREN BROS	2016-07-21
501	2014-01-01	KAREN BROS	KAREN BROS	2015-07-29
501	2014-01-01	KAREN BROS	KAREN BROS	2015-07-22
501	2013-01-01	KAREN BROS	KAREN BROS	2014-10-14
501	2012-01-01	KAREN BROS	KAREN BROS	2013-10-15
501	2011-01-01	MICHAEL FITZGIBBONS	MICHAEL FITZGIBBONS	2012-10-12

Plan Statistics for RBA, INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for RBA, INC. HEALTH & WELFARE PLAN

Measure Date Value
2022: RBA, INC. HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 175
Number of retired or separated participants receiving benefits 2022-01-01 3
Total of all active and inactive participants 2022-01-01 178
2021: RBA, INC. HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 122
Number of retired or separated participants receiving benefits 2021-01-01 1
Total of all active and inactive participants 2021-01-01 123
2020: RBA, INC. HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 116
Total of all active and inactive participants 2020-01-01 116
2019: RBA, INC. HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 111
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 112
2018: RBA, INC. HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 120
Total of all active and inactive participants 2018-01-01 120
2017: RBA, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 257
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 257
2016: RBA, INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 641
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: RBA, INC. HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: RBA, INC. HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: RBA, INC. HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 285
Total of all active and inactive participants 2013-01-01 285
2012: RBA, INC. HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 230
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 261
Total of all active and inactive participants 2012-01-01 261
2011: RBA, INC. HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 230
Total of all active and inactive participants 2011-01-01 230

Measure	Date	Value
2022: RBA, INC. HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	175
Number of retired or separated participants receiving benefits	2022-01-01	3
Total of all active and inactive participants	2022-01-01	178
2021: RBA, INC. HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	122
Number of retired or separated participants receiving benefits	2021-01-01	1
Total of all active and inactive participants	2021-01-01	123
2020: RBA, INC. HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	116
Total of all active and inactive participants	2020-01-01	116
2019: RBA, INC. HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	111
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	112
2018: RBA, INC. HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	120
Total of all active and inactive participants	2018-01-01	120
2017: RBA, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	257
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	257
2016: RBA, INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	641
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: RBA, INC. HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: RBA, INC. HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: RBA, INC. HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	285
Total of all active and inactive participants	2013-01-01	285
2012: RBA, INC. HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	230
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	261
Total of all active and inactive participants	2012-01-01	261
2011: RBA, INC. HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	230
Total of all active and inactive participants	2011-01-01	230

Financial Data on RBA, INC. HEALTH & WELFARE PLAN

Measure	Date	Value
2017 : RBA, INC. HEALTH & WELFARE PLAN 2017 401k financial data
Total income from all sources	2017-12-31	$0
Total plan assets at end of year	2017-12-31	$0
Total plan assets at beginning of year	2017-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$0
2016 : RBA, INC. HEALTH & WELFARE PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$0
Total plan assets at end of year	2016-12-31	$0
Total plan assets at beginning of year	2016-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$0
2015 : RBA, INC. HEALTH & WELFARE PLAN 2015 401k financial data
Total income from all sources	2015-12-31	$0
Total plan assets at end of year	2015-12-31	$0
Total plan assets at beginning of year	2015-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$0
2014 : RBA, INC. HEALTH & WELFARE PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$0
Total plan assets at end of year	2014-12-31	$0
Total plan assets at beginning of year	2014-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$0
2013 : RBA, INC. HEALTH & WELFARE PLAN 2013 401k financial data
Total income from all sources	2013-12-31	$0
Total plan assets at end of year	2013-12-31	$0
Total plan assets at beginning of year	2013-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$0
2012 : RBA, INC. HEALTH & WELFARE PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$0
Total plan assets at end of year	2012-12-31	$0
Total plan assets at beginning of year	2012-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$0
2011 : RBA, INC. HEALTH & WELFARE PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$0
Total plan assets at end of year	2011-12-31	$0
Total plan assets at beginning of year	2011-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0

Form 5500 Responses for RBA, INC. HEALTH & WELFARE PLAN

2022: RBA, INC. HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: RBA, INC. HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: RBA, INC. HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: RBA, INC. HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: RBA, INC. HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: RBA, INC. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: RBA, INC. HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: RBA, INC. HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: RBA, INC. HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: RBA, INC. HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: RBA, INC. HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: RBA, INC. HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47847

Policy instance

Insurance contract or identification number	47847
Number of Individuals Covered	24
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $523
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $4,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $523
Insurance broker organization code?	4

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1148270

Policy instance

Insurance contract or identification number	1148270
Number of Individuals Covered	272
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $136,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201350

Policy instance

Insurance contract or identification number	201350
Number of Individuals Covered	332
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,941
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,780,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,941
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201350

Policy instance

Insurance contract or identification number	201350
Number of Individuals Covered	245
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,184
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,149,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,184
Insurance broker organization code?	3

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	235
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,910
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $73,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1910
Additional information about fees paid to insurance broker	MARKETING ALLOWANCE
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	60
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47847

Policy instance

Insurance contract or identification number	47847
Number of Individuals Covered	17
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $477
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $2,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $477
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	62
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	272
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $40,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201350

Policy instance

Insurance contract or identification number	201350
Number of Individuals Covered	234
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,184
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,146,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,184
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201350

Policy instance

Insurance contract or identification number	201350
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	117
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	60
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	52
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	116
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $45,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201350

Policy instance

Insurance contract or identification number	201350
Number of Individuals Covered	241
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,583
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,143,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,583
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

AJ095

Policy instance

Insurance contract or identification number	AJ095
Number of Individuals Covered	257
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	AGENT/BROKER INCENTIVE PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	150
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $775
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	775
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP , LLC

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

Policy contract number

LK 751318

Policy instance

Insurance contract or identification number	LK 751318
Number of Individuals Covered	150
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $619
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	619
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

LK 963638

Policy instance

Insurance contract or identification number	LK 963638
Number of Individuals Covered	150
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $499
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	499
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

OK 966824

Policy instance

Insurance contract or identification number	OK 966824
Number of Individuals Covered	150
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $81
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	81
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	KNW GROUP, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	160
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK 751318

Policy instance

Insurance contract or identification number	LK 751318
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

AJ095

Policy instance

Insurance contract or identification number	AJ095
Number of Individuals Covered	641
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $7,706
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7706
Additional information about fees paid to insurance broker	AGENT/BROKER INCENTIVE PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP , LLC

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

Policy contract number

LK 963638

Policy instance

Insurance contract or identification number	LK 963638
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

OK 966824

Policy instance

Insurance contract or identification number	OK 966824
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	KNW GROUP, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	396
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK 751318

Policy instance

Insurance contract or identification number	LK 751318
Number of Individuals Covered	285
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

LK 963638

Policy instance

Insurance contract or identification number	LK 963638
Number of Individuals Covered	285
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

OK 966824

Policy instance

Insurance contract or identification number	OK 966824
Number of Individuals Covered	285
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	KNW GROUP, LLC

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

AJ095

Policy instance

Insurance contract or identification number	AJ095
Number of Individuals Covered	679
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $10,564
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	10564
Additional information about fees paid to insurance broker	AGENT/BROKER INCENTIVE PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	285
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP , LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	412
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK 751318

Policy instance

Insurance contract or identification number	LK 751318
Number of Individuals Covered	285
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $564
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	564
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

FLX965233

Policy instance

Insurance contract or identification number	FLX965233
Number of Individuals Covered	285
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $765
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	765
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP , LLC

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

Policy contract number

LK 963638

Policy instance

Insurance contract or identification number	LK 963638
Number of Individuals Covered	285
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $646
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	646
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	KNW GROUP, LLC

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

Policy contract number

OK 966824

Policy instance

Insurance contract or identification number	OK 966824
Number of Individuals Covered	285
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $144
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	144
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	KNW GROUP, LLC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30823

Policy instance

Insurance contract or identification number	30823
Number of Individuals Covered	363
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

AJ095

Policy instance

Insurance contract or identification number	AJ095
Number of Individuals Covered	664
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $17,250
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	17250
Additional information about fees paid to insurance broker	AGENT/BROKER INCENTIVE PAYMENTS
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	261
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,447
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,447
Additional information about fees paid to insurance broker	AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5456581

Policy instance

Insurance contract or identification number	5456581
Number of Individuals Covered	230
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $20,665
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $206,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,665
Additional information about fees paid to insurance broker	AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP LLC

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	258
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,278
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,083
Additional information about fees paid to insurance broker	AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC.

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	258
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,176
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,997
Additional information about fees paid to insurance broker	AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES, INC.

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

145933

Policy instance

Insurance contract or identification number	145933
Number of Individuals Covered	230
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $72,508
Total amount of fees paid to insurance company	USD $7,216
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,508
Amount paid for insurance broker fees	4554
Additional information about fees paid to insurance broker	AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	THE KNW GROUP, LLC/PETER KNOLL

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	229
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,679
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5456581

Policy instance

Insurance contract or identification number	5456581
Number of Individuals Covered	187
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $15,128
Total amount of fees paid to insurance company	USD $904
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	230
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,557
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

215403

Policy instance

Insurance contract or identification number	215403
Number of Individuals Covered	229
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,601
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

145933

Policy instance

Insurance contract or identification number	145933
Number of Individuals Covered	186
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,767
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	RBA, INC.
Employer identification number (EIN):	204004667
NAIC Classification:	541511
NAIC Description:	Custom Computer Programming Services