401k Plan data: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN plan

SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN
Plan identification number	501

SHOOSMITH CONSTRUCTION, INC. EMPLOYEE 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

401k Sponsoring company profile

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

Company Name: SHOOSMITH CONSTRUCTION, INC.

Employer identification number (EIN): 204124534

NAIC Classification: 237990
NAIC Description: Other Heavy and Civil Engineering Construction

Additional information about SHOOSMITH CONSTRUCTION, INC.

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 2005-11-14

Company Identification Number: 0647796

Legal Registered Office Address: 11800 LEWIS ROAD
11800 LEWIS RD
CHESTER
United States of America (USA)
23831

More information about SHOOSMITH CONSTRUCTION, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-04-01
501 2021-04-01
501 2020-04-01 ELIZABETH S. BAREFOOT 2022-01-14
501 2019-04-01 ELIZABETH S. BAREFOOT 2021-01-05 ELIZABETH S. BAREFOOT
501 2018-04-01 ELIZABETH S. BAREFOOT 2020-01-13
501 2017-04-01
501 2016-04-01
501 2015-04-01
501 2014-04-01
501 2013-04-01
501 2012-04-01 ELIZABETH S. BAREFOOT
501 2011-04-01 ELIZABETH S. BAREFOOT
501 2010-04-01 ELIZABETH S. BAREFOOT
501 2009-04-01 ELIZABETH S. BAREFOOT

Plan Statistics for SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-04-01 125
Total number of active participants reported on line 7a of the Form 5500 2022-04-01 132
Number of retired or separated participants receiving benefits 2022-04-01 0
Number of other retired or separated participants entitled to future benefits 2022-04-01 0
Total of all active and inactive participants 2022-04-01 132
2021: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-04-01 125
Total number of active participants reported on line 7a of the Form 5500 2021-04-01 125
Number of retired or separated participants receiving benefits 2021-04-01 0
Number of other retired or separated participants entitled to future benefits 2021-04-01 0
Total of all active and inactive participants 2021-04-01 125
2020: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-04-01 132
Total number of active participants reported on line 7a of the Form 5500 2020-04-01 124
Total of all active and inactive participants 2020-04-01 124
2019: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-04-01 84
Total number of active participants reported on line 7a of the Form 5500 2019-04-01 132
Total of all active and inactive participants 2019-04-01 132
2018: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 138
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 84
Total of all active and inactive participants 2018-04-01 84
2017: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-04-01 137
Total number of active participants reported on line 7a of the Form 5500 2017-04-01 138
Total of all active and inactive participants 2017-04-01 138
2016: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-04-01 131
Total number of active participants reported on line 7a of the Form 5500 2016-04-01 137
Total of all active and inactive participants 2016-04-01 137
2015: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 102
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 131
Total of all active and inactive participants 2015-04-01 131
2014: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 59
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 102
Total of all active and inactive participants 2014-04-01 102
2013: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 56
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 59
Total of all active and inactive participants 2013-04-01 59
2012: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 51
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 56
Total of all active and inactive participants 2012-04-01 56
2011: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-04-01 85
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 51
Total of all active and inactive participants 2011-04-01 51
2010: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-04-01 85
Total number of active participants reported on line 7a of the Form 5500 2010-04-01 85
Total of all active and inactive participants 2010-04-01 85
2009: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-04-01 101
Total number of active participants reported on line 7a of the Form 5500 2009-04-01 85
Total of all active and inactive participants 2009-04-01 85

Measure	Date	Value
2022: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-04-01	125
Total number of active participants reported on line 7a of the Form 5500	2022-04-01	132
Number of retired or separated participants receiving benefits	2022-04-01	0
Number of other retired or separated participants entitled to future benefits	2022-04-01	0
Total of all active and inactive participants	2022-04-01	132
2021: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-04-01	125
Total number of active participants reported on line 7a of the Form 5500	2021-04-01	125
Number of retired or separated participants receiving benefits	2021-04-01	0
Number of other retired or separated participants entitled to future benefits	2021-04-01	0
Total of all active and inactive participants	2021-04-01	125
2020: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	132
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	124
Total of all active and inactive participants	2020-04-01	124
2019: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	84
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	132
Total of all active and inactive participants	2019-04-01	132
2018: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	138
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	84
Total of all active and inactive participants	2018-04-01	84
2017: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	137
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	138
Total of all active and inactive participants	2017-04-01	138
2016: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	131
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	137
Total of all active and inactive participants	2016-04-01	137
2015: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	102
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	131
Total of all active and inactive participants	2015-04-01	131
2014: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	59
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	102
Total of all active and inactive participants	2014-04-01	102
2013: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	56
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	59
Total of all active and inactive participants	2013-04-01	59
2012: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	51
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	56
Total of all active and inactive participants	2012-04-01	56
2011: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	85
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	51
Total of all active and inactive participants	2011-04-01	51
2010: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-04-01	85
Total number of active participants reported on line 7a of the Form 5500	2010-04-01	85
Total of all active and inactive participants	2010-04-01	85
2009: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-04-01	101
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	85
Total of all active and inactive participants	2009-04-01	85

Form 5500 Responses for SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN

2022: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-04-01	Type of plan entity	Single employer plan
2022-04-01	Submission has been amended	No
2022-04-01	This submission is the final filing	No
2022-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-04-01	Plan is a collectively bargained plan	No
2022-04-01	Plan funding arrangement – Insurance	Yes
2022-04-01	Plan benefit arrangement – Insurance	Yes
2021: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-04-01	Type of plan entity	Single employer plan
2021-04-01	Submission has been amended	No
2021-04-01	This submission is the final filing	No
2021-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-04-01	Plan is a collectively bargained plan	No
2021-04-01	Plan funding arrangement – Insurance	Yes
2021-04-01	Plan benefit arrangement – Insurance	Yes
2020: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
2020-04-01	Plan funding arrangement – Insurance	Yes
2020-04-01	Plan benefit arrangement – Insurance	Yes
2019: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes
2018: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes
2017: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2016: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2015: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2014: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2013: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2012: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2011: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2010: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-04-01	Type of plan entity	Single employer plan
2010-04-01	Plan funding arrangement – Insurance	Yes
2010-04-01	Plan benefit arrangement – Insurance	Yes
2009: SHOOSMITH CONSTRUCTION, INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-04-01	Type of plan entity	Single employer plan
2009-04-01	This submission is the final filing	No
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

308966

Policy instance

Insurance contract or identification number	308966
Number of Individuals Covered	133
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $13,090
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, SUPPLEMENTAL LIFE, SUPPLEMENTAL AD&D, EAP
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 $86,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,090
Insurance broker organization code?	3

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

Policy contract number

911063

Policy instance

Insurance contract or identification number	911063
Number of Individuals Covered	130
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $672
Total amount of fees paid to insurance company	USD $14,617
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	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 $480,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $672
Amount paid for insurance broker fees	14617
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	123
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $3,241
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 $46,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,241
Insurance broker organization code?	3

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

Policy contract number

308966

Policy instance

Insurance contract or identification number	308966
Number of Individuals Covered	125
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $11,794
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, SUPPLEMENTAL LIFE, SUPPLEMENTAL 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 $85,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,794
Insurance broker organization code?	3

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

Policy contract number

0911063

Policy instance

Insurance contract or identification number	0911063
Number of Individuals Covered	156
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $673
Total amount of fees paid to insurance company	USD $23,438
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	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 $505,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $673
Amount paid for insurance broker fees	23438
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	140
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $3,401
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 $48,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,401
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	123
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $3,075
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,075
Insurance broker organization code?	3

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

Policy contract number

10057111001

Policy instance

Insurance contract or identification number	10057111001
Number of Individuals Covered	97
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $875
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $875
Insurance broker organization code?	3

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

Policy contract number

0911063

Policy instance

Insurance contract or identification number	0911063
Number of Individuals Covered	90
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $21,736
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $485,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	21736
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	120
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $504
Total amount of fees paid to insurance company	USD $30
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $504
Amount paid for insurance broker fees	30
Insurance broker organization code?	3

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	120
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $5,501
Total amount of fees paid to insurance company	USD $323
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,501
Amount paid for insurance broker fees	323
Insurance broker organization code?	3

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	64
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $4,073
Total amount of fees paid to insurance company	USD $245
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,073
Amount paid for insurance broker fees	245
Insurance broker organization code?	3

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	75
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $3,859
Total amount of fees paid to insurance company	USD $232
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,859
Amount paid for insurance broker fees	232
Insurance broker organization code?	3

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	62
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $3,392
Total amount of fees paid to insurance company	USD $438
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,392
Amount paid for insurance broker fees	438
Insurance broker organization code?	3

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	123
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $4,494
Total amount of fees paid to insurance company	USD $553
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,494
Amount paid for insurance broker fees	553
Insurance broker organization code?	3

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	123
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $414
Total amount of fees paid to insurance company	USD $56
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $414
Amount paid for insurance broker fees	56
Insurance broker organization code?	3

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

Policy contract number

0911063

Policy instance

Insurance contract or identification number	0911063
Number of Individuals Covered	132
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $22,609
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $517,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	22609
Insurance broker organization code?	3

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

Policy contract number

10057111001

Policy instance

Insurance contract or identification number	10057111001
Number of Individuals Covered	108
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $960
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $565
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	133
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $3,070
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,070
Insurance broker organization code?	3

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	77
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $3,214
Total amount of fees paid to insurance company	USD $426
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,214
Amount paid for insurance broker fees	426
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	120
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $3,001
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34
Insurance broker organization code?	3

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	68
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $3,215
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,215
Insurance broker organization code?	3

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	59
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $3,334
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,334
Insurance broker organization code?	3

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	103
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $4,174
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,174
Insurance broker organization code?	3

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	103
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $420
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $420
Insurance broker organization code?	3

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

Policy contract number

0911063

Policy instance

Insurance contract or identification number	0911063
Number of Individuals Covered	84
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $22,981
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $487,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	22981
Insurance broker organization code?	3

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

Policy contract number

10057111001

Policy instance

Insurance contract or identification number	10057111001
Number of Individuals Covered	101
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $913
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $913
Insurance broker organization code?	3

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	131
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $4,075
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,566
Insurance broker organization code?	3
Insurance broker name	SENTARA HEALTH PLANS, INC.

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

Policy contract number

0911063

Policy instance

Insurance contract or identification number	0911063
Number of Individuals Covered	138
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $24,773
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $469,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	24773
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

10057111001

Policy instance

Insurance contract or identification number	10057111001
Number of Individuals Covered	103
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $1,007
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,007
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	101
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $478
Total amount of fees paid to insurance company	USD $62
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $478
Amount paid for insurance broker fees	62
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	101
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $4,219
Total amount of fees paid to insurance company	USD $513
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,219
Amount paid for insurance broker fees	513
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	63
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $3,172
Total amount of fees paid to insurance company	USD $399
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,172
Amount paid for insurance broker fees	399
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	72
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $3,672
Total amount of fees paid to insurance company	USD $470
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,672
Amount paid for insurance broker fees	470
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	100
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,593
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,593
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	99
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,987
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,501
Insurance broker organization code?	3
Insurance broker name	SENTARA HEALTH PLANS, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*1

Policy instance

Insurance contract or identification number	2809*1
Number of Individuals Covered	5
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $20,290
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

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	82
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,111
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,111
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	131
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,817
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,817
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	131
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $480
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $480
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*COBRA

Policy instance

Insurance contract or identification number	2809*COBRA
Number of Individuals Covered	2
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $6,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	93
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $412,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	1
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
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
Welfare Benefit Premiums Paid to Carrier	USD $9,452
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

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	64
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $2,738
Total amount of fees paid to insurance company	USD $234
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,738
Amount paid for insurance broker fees	234
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	92
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,503
Total amount of fees paid to insurance company	USD $268
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,503
Amount paid for insurance broker fees	268
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	102
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $424
Total amount of fees paid to insurance company	USD $34
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,830
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
Amount paid for insurance broker fees	34
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	81
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $961
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $373,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $961
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	1
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

000500302

Policy instance

Insurance contract or identification number	000500302
Number of Individuals Covered	76
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $4,162
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,783
Insurance broker organization code?	3
Insurance broker name	SENTARA HEALTH PLANS, INC.

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	75
Insurance policy start date	2014-04-01
Insurance policy end date	3204-03-31
Total amount of commissions paid to insurance broker	USD $3,036
Total amount of fees paid to insurance company	USD $250
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,036
Amount paid for insurance broker fees	250
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*COBRA

Policy instance

Insurance contract or identification number	2809*COBRA
Number of Individuals Covered	3
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00439674

Policy instance

Insurance contract or identification number	00439674
Number of Individuals Covered	59
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,130
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,113
Insurance broker organization code?	3
Insurance broker name	ASSET MANAGEMENT GROUP, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	117
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $11,087
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $327,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,087
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	83
Insurance policy start date	2013-04-11
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $343
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $343
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	83
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,717
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,717
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*COBRA

Policy instance

Insurance contract or identification number	2809*COBRA
Number of Individuals Covered	3
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	59
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,366
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,366
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	66
Insurance policy start date	2013-04-01
Insurance policy end date	3203-03-31
Total amount of commissions paid to insurance broker	USD $2,539
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,539
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	4
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON, INC.

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

Policy contract number

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	71
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,577
Total amount of fees paid to insurance company	USD $349
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,577
Amount paid for insurance broker fees	349
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	57
Insurance policy start date	2012-04-01
Insurance policy end date	3202-03-31
Total amount of commissions paid to insurance broker	USD $2,385
Total amount of fees paid to insurance company	USD $313
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,385
Amount paid for insurance broker fees	313
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	54
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,239
Total amount of fees paid to insurance company	USD $380
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,239
Amount paid for insurance broker fees	380
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	71
Insurance policy start date	2012-04-11
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $346
Total amount of fees paid to insurance company	USD $54
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $346
Amount paid for insurance broker fees	54
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*COBRA

Policy instance

Insurance contract or identification number	2809*COBRA
Number of Individuals Covered	2
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )

Policy contract number

60592*RETIREE

Policy instance

Insurance contract or identification number	60592*RETIREE
Number of Individuals Covered	2
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	125
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $11,834
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $379,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,834
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	4
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON

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

Policy contract number

00439674

Policy instance

Insurance contract or identification number	00439674
Number of Individuals Covered	56
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,299
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,281
Insurance broker organization code?	3
Insurance broker name	ASSET MANAGEMENT GROUP

OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )

Policy contract number

60592*RETIREE

Policy instance

Insurance contract or identification number	60592*RETIREE
Number of Individuals Covered	2
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,758
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

SGM602386

Policy instance

Insurance contract or identification number	SGM602386
Number of Individuals Covered	64
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,187
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00439674

Policy instance

Insurance contract or identification number	00439674
Number of Individuals Covered	51
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,495
Total amount of fees paid to insurance company	USD $2,497
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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 $37,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	132
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $12,608
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $409,572
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

VDT600463

Policy instance

Insurance contract or identification number	VDT600463
Number of Individuals Covered	54
Insurance policy start date	2011-04-01
Insurance policy end date	3201-03-31
Total amount of commissions paid to insurance broker	USD $2,811
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,738
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

VDT600464

Policy instance

Insurance contract or identification number	VDT600464
Number of Individuals Covered	49
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,607
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3259637

Policy instance

Insurance contract or identification number	E3259637
Number of Individuals Covered	19
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,482
Total amount of fees paid to insurance company	USD $151
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
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

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	4
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,442
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

SOK601470

Policy instance

Insurance contract or identification number	SOK601470
Number of Individuals Covered	64
Insurance policy start date	2011-04-11
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $400
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

60592

Policy instance

Insurance contract or identification number	60592
Number of Individuals Covered	2
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $267
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )

Policy contract number

60592*RETIREE

Policy instance

Insurance contract or identification number	60592*RETIREE
Number of Individuals Covered	2
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*CARRA

Policy instance

Insurance contract or identification number	2809*CARRA
Number of Individuals Covered	1
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3259637

Policy instance

Insurance contract or identification number	E3259637
Number of Individuals Covered	26
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $2,319
Total amount of fees paid to insurance company	USD $232
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00439674

Policy instance

Insurance contract or identification number	00439674
Number of Individuals Covered	85
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $11,389
Total amount of fees paid to insurance company	USD $5,884
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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 $102,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809*OWNER

Policy instance

Insurance contract or identification number	2809*OWNER
Number of Individuals Covered	4
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )

Policy contract number

2809

Policy instance

Insurance contract or identification number	2809
Number of Individuals Covered	147
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $12,753
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $408,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SHOOSMITH CONSTRUCTION, INC.
Employer identification number (EIN):	204124534
NAIC Classification:	237990
NAIC Description:	Other Heavy and Civil Engineering Construction

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	2005-11-14
Company Identification Number:	0647796
Legal Registered Office Address:	11800 LEWIS ROAD 11800 LEWIS RD CHESTER United States of America (USA) 23831