401k Plan data: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN plan

CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN
Plan identification number	501

CHERRYROAD TECHNOLOGIES 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 Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CHERRYROAD TECHNOLOGIES INC. has sponsored the creation of one or more 401k plans.

Company Name: CHERRYROAD TECHNOLOGIES INC.

Employer identification number (EIN): 205084389

NAIC Classification: 541600

Additional information about CHERRYROAD TECHNOLOGIES INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 2006-06-20

Company Identification Number: P06000083970

Legal Registered Office Address: 925 LAKE WYMAN RD.

BOCA RATON

33431

More information about CHERRYROAD TECHNOLOGIES INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JEREMY GULBAN 2023-05-30 JEREMY GULBAN 2023-05-30
501 2021-01-01 JEREMY GULBAN 2022-05-06 JEREMY GULBAN 2022-05-06
501 2020-01-01 JEREMY GULBAN 2021-07-27 JEREMY GULBAN 2021-07-27
501 2019-01-01 JEREMY GULBAN 2020-07-16 JEREMY GULBAN 2020-07-16
501 2018-01-01 JEREMY GULBAN JEREMY GULBAN 2019-07-19
501 2018-01-01 JEREMY GULBAN JEREMY GULBAN 2019-07-19
501 2018-01-01 JEREMY GULBAN 2019-07-19 JEREMY GULBAN 2019-07-19
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JEREMY GULBAN
501 2011-01-01 JEREMY GULBAN
501 2009-01-01 JEREMY GULBAN JEREMY GULBAN 2010-06-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JEREMY GULBAN	2023-05-30	JEREMY GULBAN	2023-05-30
501	2021-01-01	JEREMY GULBAN	2022-05-06	JEREMY GULBAN	2022-05-06
501	2020-01-01	JEREMY GULBAN	2021-07-27	JEREMY GULBAN	2021-07-27
501	2019-01-01	JEREMY GULBAN	2020-07-16	JEREMY GULBAN	2020-07-16
501	2018-01-01	JEREMY GULBAN		JEREMY GULBAN	2019-07-19
501	2018-01-01	JEREMY GULBAN		JEREMY GULBAN	2019-07-19
501	2018-01-01	JEREMY GULBAN	2019-07-19	JEREMY GULBAN	2019-07-19
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	JEREMY GULBAN
501	2011-01-01	JEREMY GULBAN
501	2009-01-01	JEREMY GULBAN		JEREMY GULBAN	2010-06-14

Plan Statistics for CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 331
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 409
Number of retired or separated participants receiving benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 409
2021: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 331
Number of retired or separated participants receiving benefits 2021-01-01 4
Total of all active and inactive participants 2021-01-01 335
2020: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 265
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 278
Number of retired or separated participants receiving benefits 2020-01-01 3
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 281
2019: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 263
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 265
Number of retired or separated participants receiving benefits 2019-01-01 7
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 272
2018: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 263
Number of retired or separated participants receiving benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 266
2017: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 199
Number of retired or separated participants receiving benefits 2017-01-01 2
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 201
2016: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 152
Number of retired or separated participants receiving benefits 2016-01-01 4
Total of all active and inactive participants 2016-01-01 156
2015: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 143
Number of retired or separated participants receiving benefits 2015-01-01 2
Total of all active and inactive participants 2015-01-01 145
2014: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 144
Number of retired or separated participants receiving benefits 2014-01-01 9
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 153
2013: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 198
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 170
Number of retired or separated participants receiving benefits 2013-01-01 11
Total of all active and inactive participants 2013-01-01 181
2012: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 158
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 196
Number of retired or separated participants receiving benefits 2012-01-01 2
Total of all active and inactive participants 2012-01-01 198
2011: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 187
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 156
Number of retired or separated participants receiving benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 158
2009: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 140
Number of retired or separated participants receiving benefits 2009-01-01 11
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 151
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 1
Total participants 2009-01-01 152

Measure	Date	Value
2022: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	331
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	409
Number of retired or separated participants receiving benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	409
2021: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	331
Number of retired or separated participants receiving benefits	2021-01-01	4
Total of all active and inactive participants	2021-01-01	335
2020: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	278
Number of retired or separated participants receiving benefits	2020-01-01	3
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	281
2019: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	263
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	265
Number of retired or separated participants receiving benefits	2019-01-01	7
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	272
2018: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	263
Number of retired or separated participants receiving benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	266
2017: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	199
Number of retired or separated participants receiving benefits	2017-01-01	2
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	201
2016: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	152
Number of retired or separated participants receiving benefits	2016-01-01	4
Total of all active and inactive participants	2016-01-01	156
2015: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	143
Number of retired or separated participants receiving benefits	2015-01-01	2
Total of all active and inactive participants	2015-01-01	145
2014: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	144
Number of retired or separated participants receiving benefits	2014-01-01	9
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	153
2013: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	198
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	170
Number of retired or separated participants receiving benefits	2013-01-01	11
Total of all active and inactive participants	2013-01-01	181
2012: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	196
Number of retired or separated participants receiving benefits	2012-01-01	2
Total of all active and inactive participants	2012-01-01	198
2011: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	187
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	156
Number of retired or separated participants receiving benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	158
2009: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	140
Number of retired or separated participants receiving benefits	2009-01-01	11
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	151
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	1
Total participants	2009-01-01	152

Form 5500 Responses for CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN

2022: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	Yes
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: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: CHERRYROAD TECHNOLOGIES INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	337
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $93,609
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,873,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93,609
Insurance broker organization code?	3

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	675
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,436
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,436
Insurance broker organization code?	3

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	722
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
Welfare Benefit Premiums Paid to Carrier	USD $37,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	388
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $2,814
Total amount of fees paid to insurance company	USD $1,067
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $45,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,093
Insurance broker organization code?	3
Amount paid for insurance broker fees	278
Additional information about fees paid to insurance broker	OVERRIDE AND BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010269024

Policy instance

Insurance contract or identification number	000010269024
Number of Individuals Covered	363
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,893
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,893
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

56433

Policy instance

Insurance contract or identification number	56433
Insurance policy start date	2021-12-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $505
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $505
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	115
Insurance policy start date	2021-08-01
Insurance policy end date	2022-08-01
Total amount of commissions paid to insurance broker	USD $17,782
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,782
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	160
Insurance policy start date	2021-08-01
Insurance policy end date	2022-08-01
Total amount of commissions paid to insurance broker	USD $4,728
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,728
Insurance broker organization code?	3

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	115
Insurance policy start date	2021-08-01
Insurance policy end date	2022-08-01
Total amount of commissions paid to insurance broker	USD $4,431
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $4,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,431
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	100
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $13,597
Total amount of fees paid to insurance company	USD $824
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,597
Amount paid for insurance broker fees	824
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 )

Policy contract number

56433

Policy instance

Insurance contract or identification number	56433
Number of Individuals Covered	1
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $658
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $658
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

00533964

Policy instance

Insurance contract or identification number	00533964
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,337
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,337
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	254
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $70,329
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,900,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,329
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	147
Insurance policy start date	2021-05-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $902
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $902
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	147
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $4,903
Total amount of fees paid to insurance company	USD $492
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,903
Amount paid for insurance broker fees	492
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	100
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $681
Total amount of fees paid to insurance company	USD $48
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $3,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $681
Amount paid for insurance broker fees	48
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	100
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $162
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $162
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	100
Insurance policy start date	2021-05-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $3,270
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,270
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	331
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $2,167
Total amount of fees paid to insurance company	USD $2,953
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $31,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,167
Amount paid for insurance broker fees	2953
Additional information about fees paid to insurance broker	OVERRIDE AND BONUS
Insurance broker organization code?	3

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	600
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 $28,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	563
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,538
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,538
Insurance broker organization code?	3

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	544
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,521
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid as a credit?	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 $6,521
Insurance broker organization code?	3

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	575
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 $30,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	273
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $2,790
Total amount of fees paid to insurance company	USD $2,951
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $34,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,790
Amount paid for insurance broker fees	2951
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	3

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	98
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $1,124
Total amount of fees paid to insurance company	USD $42
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $5,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,124
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	98
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $20,810
Total amount of fees paid to insurance company	USD $821
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,810
Amount paid for insurance broker fees	821
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	149
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $5,935
Total amount of fees paid to insurance company	USD $425
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,935
Amount paid for insurance broker fees	425
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

00533964

Policy instance

Insurance contract or identification number	00533964
Number of Individuals Covered	233
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,075
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,253
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
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND SERVICES
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	265
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $74,261
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,076,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74,261
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	582
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,475
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,475
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	237
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $2,153
Total amount of fees paid to insurance company	USD $2,846
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $27,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,153
Amount paid for insurance broker fees	2846
Additional information about fees paid to insurance broker	SALES AND SERVICES
Insurance broker organization code?	3

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	534
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 $26,779
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

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	101
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $1,139
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $5,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,139
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	101
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $22,336
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,336
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	149
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $5,732
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,732
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	218
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $76,471
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,153,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,471
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

00533964

Policy instance

Insurance contract or identification number	00533964
Number of Individuals Covered	209
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,635
Total amount of fees paid to insurance company	USD $1,864
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,635
Amount paid for insurance broker fees	1864
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	583
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,681
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,681
Insurance broker organization code?	3

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	550
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 $26,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	250
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $2,262
Total amount of fees paid to insurance company	USD $1,551
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $24,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,262
Amount paid for insurance broker fees	1551
Additional information about fees paid to insurance broker	OVERRIDES AND BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	115
Insurance policy start date	2017-08-01
Insurance policy end date	2018-08-01
Total amount of commissions paid to insurance broker	USD $962
Total amount of fees paid to insurance company	USD $64
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $4,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $962
Amount paid for insurance broker fees	64
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	114
Insurance policy start date	2017-08-01
Insurance policy end date	2018-08-01
Total amount of commissions paid to insurance broker	USD $17,815
Total amount of fees paid to insurance company	USD $1,141
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,815
Amount paid for insurance broker fees	1141
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	158
Insurance policy start date	2017-08-01
Insurance policy end date	2018-08-01
Total amount of commissions paid to insurance broker	USD $4,964
Total amount of fees paid to insurance company	USD $689
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,964
Amount paid for insurance broker fees	689
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	216
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $73,403
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,041,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,403
Insurance broker organization code?	3

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

Policy contract number

00533964

Policy instance

Insurance contract or identification number	00533964
Number of Individuals Covered	181
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,432
Total amount of fees paid to insurance company	USD $2,110
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,432
Amount paid for insurance broker fees	2110
Insurance broker organization code?	3

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

86659

Policy instance

Insurance contract or identification number	86659
Number of Individuals Covered	127
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $54,937
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,178,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,937
Insurance broker organization code?	3
Insurance broker name	NORTHEAST BENEFITS

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	135
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $3,964
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,964
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY INC.

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	88
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $11,739
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,739
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY INC.

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

Policy contract number

SOK603761

Policy instance

Insurance contract or identification number	SOK603761
Number of Individuals Covered	88
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $679
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $3,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $679
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	192
Insurance policy start date	2016-10-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $1,653
Total amount of fees paid to insurance company	USD $1,233
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,653
Amount paid for insurance broker fees	1233
Additional information about fees paid to insurance broker	OVERRIDES AND BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

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

Policy contract number

98633901001

Policy instance

Insurance contract or identification number	98633901001
Number of Individuals Covered	475
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	198
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,397
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,397
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

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

Policy contract number

5469009

Policy instance

Insurance contract or identification number	5469009
Number of Individuals Covered	141
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,013
Total amount of fees paid to insurance company	USD $558
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,013
Amount paid for insurance broker fees	558
Additional information about fees paid to insurance broker	BROKERS BROKER FEE
Insurance broker organization code?	3
Insurance broker name	ERC OF NEW YORK DBA EMERSON REID CO

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

Policy contract number

417005410943

Policy instance

Insurance contract or identification number	417005410943
Number of Individuals Covered	398
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $7,821
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $156,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,821
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010209141

Policy instance

Insurance contract or identification number	000010209141
Number of Individuals Covered	142
Insurance policy start date	2015-10-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $427
Total amount of fees paid to insurance company	USD $153
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $427
Amount paid for insurance broker fees	153
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Insurance broker name	EMERSON REID & CO INC.

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

Policy contract number

VDT601281

Policy instance

Insurance contract or identification number	VDT601281
Number of Individuals Covered	111
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $3,618
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,618
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY

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

Policy contract number

SGM605478

Policy instance

Insurance contract or identification number	SGM605478
Number of Individuals Covered	58
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $8,542
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,542
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	125
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,620
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,620
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

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

Policy contract number

SDK603761

Policy instance

Insurance contract or identification number	SDK603761
Number of Individuals Covered	58
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $564
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $564
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY

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

Policy contract number

9863390

Policy instance

Insurance contract or identification number	9863390
Number of Individuals Covered	290
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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 $14,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

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

Policy contract number

417005410943

Policy instance

Insurance contract or identification number	417005410943
Number of Individuals Covered	131
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,767
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
Welfare Benefit Premiums Paid to Carrier	USD $156,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,767
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

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

Policy contract number

5469009

Policy instance

Insurance contract or identification number	5469009
Number of Individuals Covered	148
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,500
Total amount of fees paid to insurance company	USD $821
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
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $16,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,500
Amount paid for insurance broker fees	821
Additional information about fees paid to insurance broker	FEES FOR GROUP TERM LIFE INSURANCE
Insurance broker organization code?	3
Insurance broker name	ERC OF NY DBA EMERSON REID & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

4000010000 1029

Policy instance

Insurance contract or identification number	4000010000 1029
Number of Individuals Covered	63
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $7,351
Total amount of fees paid to insurance company	USD $2,761
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
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,351
Insurance broker organization code?	3
Amount paid for insurance broker fees	2761
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	WILLIS OF ARIZONA

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10084646 00000

Policy instance

Insurance contract or identification number	10084646 00000
Number of Individuals Covered	119
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $2,821
Total amount of fees paid to insurance company	USD $1,874
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 $28,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,821
Insurance broker organization code?	3
Amount paid for insurance broker fees	1874
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	WILLIS OF ARIZONA

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	123
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,540
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,540
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

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

Policy contract number

9863390

Policy instance

Insurance contract or identification number	9863390
Number of Individuals Covered	341
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

9863390

Policy instance

Insurance contract or identification number	9863390
Number of Individuals Covered	361
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,962
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

5469009

Policy instance

Insurance contract or identification number	5469009
Number of Individuals Covered	175
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $465
Total amount of fees paid to insurance company	USD $418
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
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $465
Amount paid for insurance broker fees	232
Additional information about fees paid to insurance broker	BROKERS BROKER FEE
Insurance broker organization code?	3
Insurance broker name	ERC OF NEW YORK DBA EMERSON REID CO

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

Policy contract number

417003410943

Policy instance

Insurance contract or identification number	417003410943
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

4000010000 1029

Policy instance

Insurance contract or identification number	4000010000 1029
Number of Individuals Covered	83
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $16,992
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
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $84,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,749
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10084646 00000

Policy instance

Insurance contract or identification number	10084646 00000
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,768
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 $57,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,464
Insurance broker organization code?	3
Insurance broker name	WILLIS OF NEW JERSEY

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	150
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,529
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,529
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

417004410943

Policy instance

Insurance contract or identification number	417004410943
Number of Individuals Covered	157
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $18,211
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
Welfare Benefit Premiums Paid to Carrier	USD $364,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,211
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00033396

Policy instance

Insurance contract or identification number	G00033396
Number of Individuals Covered	198
Insurance policy start date	2013-01-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $2,853
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,853
Insurance broker organization code?	3
Insurance broker name	ROBERT VAN RIPER AGENCY

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

Policy contract number

417003410943

Policy instance

Insurance contract or identification number	417003410943
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,003
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
Welfare Benefit Premiums Paid to Carrier	USD $99,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,003
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

4000010000 1029

Policy instance

Insurance contract or identification number	4000010000 1029
Number of Individuals Covered	91
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,246
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
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $66,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,246
Insurance broker organization code?	3
Insurance broker name	JOHN G. WAPELHORST

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10084646 00000

Policy instance

Insurance contract or identification number	10084646 00000
Number of Individuals Covered	152
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,638
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 $56,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,638
Insurance broker organization code?	3
Insurance broker name	JOHN G. WAPELHORST

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00033396

Policy instance

Insurance contract or identification number	G 00033396
Number of Individuals Covered	197
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,296
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
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,296
Insurance broker organization code?	3
Insurance broker name	ROBERT VAN RIPER INSURANCE AGENCY

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

16535

Policy instance

Insurance contract or identification number	16535
Number of Individuals Covered	165
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,091
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
Welfare Benefit Premiums Paid to Carrier	USD $202,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,091
Insurance broker name	RICHARDS AND SUMMERS INC.

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	163
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,931
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,931
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

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

Policy contract number

PL-213243

Policy instance

Insurance contract or identification number	PL-213243
Number of Individuals Covered	148
Insurance policy start date	2011-01-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $9,716
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
Welfare Benefit Premiums Paid to Carrier	USD $127,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00033396

Policy instance

Insurance contract or identification number	G 00033396
Number of Individuals Covered	158
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,876
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Number of Individuals Covered	131
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,908
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10084646 00000

Policy instance

Insurance contract or identification number	10084646 00000
Number of Individuals Covered	125
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,331
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 $43,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

417003410943

Policy instance

Insurance contract or identification number	417003410943
Number of Individuals Covered	129
Insurance policy start date	2011-05-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,544
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
Welfare Benefit Premiums Paid to Carrier	USD $191,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

4000010000 1029

Policy instance

Insurance contract or identification number	4000010000 1029
Number of Individuals Covered	65
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,843
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
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $44,217
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

PL-213243

Policy instance

Insurance contract or identification number	PL-213243
Number of Individuals Covered	129
Insurance policy start date	2010-05-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $231,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

4000010000 1029

Policy instance

Insurance contract or identification number	4000010000 1029
Number of Individuals Covered	81
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,503
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
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,503
Insurance broker name	JOHN G. WAPELHORST

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10084646 00000

Policy instance

Insurance contract or identification number	10084646 00000
Number of Individuals Covered	143
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,304
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 $43,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,304
Insurance broker organization code?	3
Insurance broker name	JOHN G. WAPELHORST

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00033396

Policy instance

Insurance contract or identification number	G 00033396
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,074
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,074
Additional information about fees paid to insurance broker	PREMIUMS
Insurance broker organization code?	3
Insurance broker name	ROBERT VAN RIPER INSURANCE

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

2675

Policy instance

Insurance contract or identification number	2675
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,730
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,730
Insurance broker organization code?	3
Insurance broker name	RICHARDS AND SUMMERS INC.

MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

PL-98223

Policy instance

Insurance contract or identification number	PL-98223
Number of Individuals Covered	129
Insurance policy start date	2010-01-01
Insurance policy end date	2010-04-30
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
Welfare Benefit Premiums Paid to Carrier	USD $72,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CHERRYROAD TECHNOLOGIES INC.
Employer identification number (EIN):	205084389
NAIC Classification:	541600

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	2006-06-20
Company Identification Number:	P06000083970
Legal Registered Office Address:	925 LAKE WYMAN RD. BOCA RATON 33431