401k Plan data: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN plan

COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN
Plan identification number	501

COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover

401k Sponsoring company profile

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

Company Name: COUNTY SERVICES, INC.

Employer identification number (EIN): 205095170

NAIC Classification: 311610
NAIC Description: Animal Slaughtering and Processing

Additional information about COUNTY SERVICES, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1995-04-04

Company Identification Number: 1909742

Legal Registered Office Address: 9 FERN OVAL WEST
Rockland
ORANGEBURG
United States of America (USA)
10962

More information about COUNTY SERVICES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 GARTH MERRICK
501 2017-01-01 GARTH MERRICK
501 2016-08-01
501 2015-08-01
501 2014-08-01
501 2013-08-01
501 2012-08-01 GARTH MERRICK
501 2011-08-01 GARTH MERRICK

Plan Statistics for COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2022: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 89
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 189
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 189
2021: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 165
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 89
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 89
2020: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 165
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 165
2019: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 179
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 179
2018: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 198
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 221
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 221
2017: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 198
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 198
2016: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-08-01 169
Total number of active participants reported on line 7a of the Form 5500 2016-08-01 171
Total of all active and inactive participants 2016-08-01 171
2015: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-08-01 154
Total number of active participants reported on line 7a of the Form 5500 2015-08-01 169
Total of all active and inactive participants 2015-08-01 169
2014: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-08-01 140
Total number of active participants reported on line 7a of the Form 5500 2014-08-01 154
Total of all active and inactive participants 2014-08-01 154
2013: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-08-01 124
Total number of active participants reported on line 7a of the Form 5500 2013-08-01 140
Total of all active and inactive participants 2013-08-01 140
2012: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-08-01 129
Total number of active participants reported on line 7a of the Form 5500 2012-08-01 124
Total of all active and inactive participants 2012-08-01 124
2011: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-08-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-08-01 129
Total of all active and inactive participants 2011-08-01 129

Measure	Date	Value
2022: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	89
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	189
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	189
2021: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	165
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	89
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	89
2020: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	165
Number of retired or separated participants receiving benefits	2020-01-01	0
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	165
2019: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	179
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	179
2018: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	198
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	221
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	221
2017: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	198
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	198
2016: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	169
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	171
Total of all active and inactive participants	2016-08-01	171
2015: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	154
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	169
Total of all active and inactive participants	2015-08-01	169
2014: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	140
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	154
Total of all active and inactive participants	2014-08-01	154
2013: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-08-01	124
Total number of active participants reported on line 7a of the Form 5500	2013-08-01	140
Total of all active and inactive participants	2013-08-01	140
2012: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-08-01	129
Total number of active participants reported on line 7a of the Form 5500	2012-08-01	124
Total of all active and inactive participants	2012-08-01	124
2011: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-08-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-08-01	129
Total of all active and inactive participants	2011-08-01	129

Form 5500 Responses for COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN

2022: COUNTY SERVICES, INC. HEALTH & WELFARE 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 benefit arrangement – Insurance	Yes
2021: COUNTY SERVICES, INC. HEALTH & WELFARE 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 benefit arrangement – Insurance	Yes
2020: COUNTY SERVICES, INC. HEALTH & WELFARE 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 benefit arrangement – Insurance	Yes
2019: COUNTY SERVICES, INC. HEALTH & WELFARE 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 benefit arrangement – Insurance	Yes
2018: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: COUNTY SERVICES, INC. HEALTH & WELFARE 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 benefit arrangement – Insurance	Yes
2016: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-08-01	Plan funding arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2015: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2014: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Plan funding arrangement – Insurance	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2013: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-08-01	Type of plan entity	Single employer plan
2013-08-01	Plan funding arrangement – Insurance	Yes
2013-08-01	Plan benefit arrangement – Insurance	Yes
2012: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-08-01	Type of plan entity	Single employer plan
2012-08-01	Plan funding arrangement – Insurance	Yes
2012-08-01	Plan benefit arrangement – Insurance	Yes
2011: COUNTY SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-08-01	Type of plan entity	Single employer plan
2011-08-01	First time form 5500 has been submitted	Yes
2011-08-01	Plan funding arrangement – Insurance	Yes
2011-08-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GVTL0BT8J

Policy instance

Insurance contract or identification number	GVTL0BT8J
Number of Individuals Covered	32
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,758
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TERM LIFE - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $18,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,758
Insurance broker organization code?	3

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

Policy contract number

GLUG0BT8J

Policy instance

Insurance contract or identification number	GLUG0BT8J
Number of Individuals Covered	101
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,054
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,054
Insurance broker organization code?	3

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

Policy contract number

GLTD0BT8J

Policy instance

Insurance contract or identification number	GLTD0BT8J
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $984
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $984
Insurance broker organization code?	3

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

Policy contract number

GLLV0BT8J

Policy instance

Insurance contract or identification number	GLLV0BT8J
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $65
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-058539

Policy instance

Insurance contract or identification number	010-058539
Number of Individuals Covered	151
Insurance policy start date	2022-02-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,857
Total amount of fees paid to insurance company	USD $585
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,857
Amount paid for insurance broker fees	585
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

920686

Policy instance

Insurance contract or identification number	920686
Number of Individuals Covered	189
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $16,320
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $824,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,320
Insurance broker organization code?	3

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

Policy contract number

GUDB0BT8J

Policy instance

Insurance contract or identification number	GUDB0BT8J
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $301
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $301
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMDC0BT8J

Policy instance

Insurance contract or identification number	GMDC0BT8J
Number of Individuals Covered	57
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $529
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D VOLUNTARY STAND ALONE
Welfare Benefit Premiums Paid to Carrier	USD $3,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $529
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-890-467010

Policy instance

Insurance contract or identification number	SA3-890-467010
Number of Individuals Covered	95
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $8,419
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,419
Insurance broker organization code?	3

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

Policy contract number

GLLV0BT8J

Policy instance

Insurance contract or identification number	GLLV0BT8J
Number of Individuals Covered	58
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $773
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $773
Insurance broker organization code?	3

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

Policy contract number

0920686

Policy instance

Insurance contract or identification number	0920686
Number of Individuals Covered	89
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,305
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $579,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,305
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-890-467010

Policy instance

Insurance contract or identification number	GF3-890-467010
Number of Individuals Covered	20
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $781
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $781
Insurance broker organization code?	3

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

Policy contract number

GLTD0BT8J

Policy instance

Insurance contract or identification number	GLTD0BT8J
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $758
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $758
Insurance broker organization code?	3

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

Policy contract number

GLUG0BT8J

Policy instance

Insurance contract or identification number	GLUG0BT8J
Number of Individuals Covered	93
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,763
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,763
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMDC0BT8J

Policy instance

Insurance contract or identification number	GMDC0BT8J
Number of Individuals Covered	60
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $519
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $519
Insurance broker organization code?	3

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

Policy contract number

GUDB0BT8J

Policy instance

Insurance contract or identification number	GUDB0BT8J
Number of Individuals Covered	61
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,692
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,692
Insurance broker organization code?	3

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

Policy contract number

GVTL0BT8J

Policy instance

Insurance contract or identification number	GVTL0BT8J
Number of Individuals Covered	31
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,070
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,070
Insurance broker organization code?	3

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

Policy contract number

0920686

Policy instance

Insurance contract or identification number	0920686
Number of Individuals Covered	165
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,677
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $483,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,677
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	127
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,091
Total amount of fees paid to insurance company	USD $232
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,091
Amount paid for insurance broker fees	232
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-890-467010

Policy instance

Insurance contract or identification number	SA3-890-467010
Number of Individuals Covered	65
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $15,362
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,362
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-890-467010

Policy instance

Insurance contract or identification number	GF3-890-467010
Number of Individuals Covered	13
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-01
Total amount of commissions paid to insurance broker	USD $1,119
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,119
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-890-467010

Policy instance

Insurance contract or identification number	GF3-890-467010
Number of Individuals Covered	20
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $723
Total amount of fees paid to insurance company	USD $117
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $723
Amount paid for insurance broker fees	117
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-890-467010

Policy instance

Insurance contract or identification number	SA3-890-467010
Number of Individuals Covered	116
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $9,592
Total amount of fees paid to insurance company	USD $1,536
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,592
Amount paid for insurance broker fees	1536
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

3622

Policy instance

Insurance contract or identification number	3622
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,999
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,999
Insurance broker organization code?	3

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	132
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,165
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,165
Insurance broker organization code?	3

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

3622

Policy instance

Insurance contract or identification number	3622
Number of Individuals Covered	173
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,579
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $428,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,579
Insurance broker organization code?	3

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

3622

Policy instance

Insurance contract or identification number	3622
Number of Individuals Covered	221
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $334,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	156
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,688
Total amount of fees paid to insurance company	USD $824
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,268
Amount paid for insurance broker fees	824
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-890-467010

Policy instance

Insurance contract or identification number	SA3-890-467010
Number of Individuals Covered	120
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $5,592
Total amount of fees paid to insurance company	USD $1,136
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,592
Amount paid for insurance broker fees	1136
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-890-467010

Policy instance

Insurance contract or identification number	GF3-890-467010
Number of Individuals Covered	19
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $398
Total amount of fees paid to insurance company	USD $80
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $398
Amount paid for insurance broker fees	80
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-890-467010

Policy instance

Insurance contract or identification number	GF3-890-467010
Number of Individuals Covered	18
Insurance policy start date	2017-04-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $398
Total amount of fees paid to insurance company	USD $60
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $398
Amount paid for insurance broker fees	60
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-890-467010

Policy instance

Insurance contract or identification number	SA3-890-467010
Number of Individuals Covered	115
Insurance policy start date	2017-04-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,592
Total amount of fees paid to insurance company	USD $842
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,592
Amount paid for insurance broker fees	842
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746-12

Policy instance

Insurance contract or identification number	010-030746-12
Number of Individuals Covered	28
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $185
Total amount of fees paid to insurance company	USD $449
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $185
Amount paid for insurance broker fees	449
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746-10

Policy instance

Insurance contract or identification number	010-030746-10
Number of Individuals Covered	41
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,022
Total amount of fees paid to insurance company	USD $449
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,022
Amount paid for insurance broker fees	449
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

3622

Policy instance

Insurance contract or identification number	3622
Number of Individuals Covered	198
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $198,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010400

Policy instance

Insurance contract or identification number	P31T010400
Number of Individuals Covered	1
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010300

Policy instance

Insurance contract or identification number	H31T010300
Number of Individuals Covered	113
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $12,287
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,287
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010300

Policy instance

Insurance contract or identification number	P31T010300
Number of Individuals Covered	49
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $16,695
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $305,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,695
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010400

Policy instance

Insurance contract or identification number	H31T010400
Number of Individuals Covered	34
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T020003

Policy instance

Insurance contract or identification number	P31T020003
Number of Individuals Covered	17
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $3,735
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,735
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	169
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $6,156
Total amount of fees paid to insurance company	USD $706
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,156
Amount paid for insurance broker fees	706
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

F1M745

Policy instance

Insurance contract or identification number	F1M745
Number of Individuals Covered	126
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $10,480
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $52,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,480
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010400

Policy instance

Insurance contract or identification number	P31T010400
Number of Individuals Covered	3
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010300

Policy instance

Insurance contract or identification number	P31T010300
Number of Individuals Covered	54
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $336,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AJFP

Policy instance

Insurance contract or identification number	GLUG0AJFP
Number of Individuals Covered	133
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $7,094
Total amount of fees paid to insurance company	USD $1,433
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $35,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,094
Amount paid for insurance broker fees	1433
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	154
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $5,288
Total amount of fees paid to insurance company	USD $1,084
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,288
Amount paid for insurance broker fees	1084
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010300

Policy instance

Insurance contract or identification number	H31T010300
Number of Individuals Covered	122
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AJFP

Policy instance

Insurance contract or identification number	GLTD0AJFP
Number of Individuals Covered	17
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $830
Total amount of fees paid to insurance company	USD $170
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 $4,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $830
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010400

Policy instance

Insurance contract or identification number	H31T010400
Number of Individuals Covered	30
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AJFP

Policy instance

Insurance contract or identification number	GVTL0AJFP
Number of Individuals Covered	49
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $2,248
Total amount of fees paid to insurance company	USD $432
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	AD&D - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $11,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,248
Amount paid for insurance broker fees	432
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010300

Policy instance

Insurance contract or identification number	H31T010300
Number of Individuals Covered	104
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T01

Policy instance

Insurance contract or identification number	P31T01
Number of Individuals Covered	56
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $27,051
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $339,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,051
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	140
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $4,557
Total amount of fees paid to insurance company	USD $991
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,557
Amount paid for insurance broker fees	991
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

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

Policy contract number

GLUG0AJFP

Policy instance

Insurance contract or identification number	GLUG0AJFP
Number of Individuals Covered	130
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $6,490
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,490
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T020003

Policy instance

Insurance contract or identification number	P31T020003
Number of Individuals Covered	21
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AJFP

Policy instance

Insurance contract or identification number	GLTD0AJFP
Number of Individuals Covered	16
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $795
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 $3,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $795
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

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

Policy contract number

GVTL0AJFP

Policy instance

Insurance contract or identification number	GVTL0AJFP
Number of Individuals Covered	30
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $1,951
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	AD&D - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $9,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,951
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010300

Policy instance

Insurance contract or identification number	P31T010300
Number of Individuals Covered	83
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $27,802
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $425,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,802
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010400

Policy instance

Insurance contract or identification number	H31T010400
Number of Individuals Covered	23
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	149
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $5,041
Total amount of fees paid to insurance company	USD $1,040
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,041
Amount paid for insurance broker fees	1040
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

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

Policy contract number

GLUG0AJFP

Policy instance

Insurance contract or identification number	GLUG0AJFP
Number of Individuals Covered	124
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $6,322
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,322
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

P31T010400

Policy instance

Insurance contract or identification number	P31T010400
Number of Individuals Covered	24
Insurance policy start date	2012-07-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $106,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AJFP

Policy instance

Insurance contract or identification number	GLTD0AJFP
Number of Individuals Covered	17
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $821
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 $4,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $821
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

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

Policy contract number

GVTL0AJFP

Policy instance

Insurance contract or identification number	GVTL0AJFP
Number of Individuals Covered	35
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $2,039
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	AD&D - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $10,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,039
Insurance broker organization code?	3
Insurance broker name	UPSHAW INSURANCE AGENCY INC

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T010300

Policy instance

Insurance contract or identification number	H31T010300
Number of Individuals Covered	85
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

H31T01

Policy instance

Insurance contract or identification number	H31T01
Number of Individuals Covered	100
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $7,231
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $135,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

P31T01

Policy instance

Insurance contract or identification number	P31T01
Number of Individuals Covered	102
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $25,501
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $474,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-030746

Policy instance

Insurance contract or identification number	010-030746
Number of Individuals Covered	107
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $3,133
Total amount of fees paid to insurance company	USD $793
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G000AJFP

Policy instance

Insurance contract or identification number	G000AJFP
Number of Individuals Covered	129
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $6,374
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	COUNTY SERVICES, INC.
Employer identification number (EIN):	205095170
NAIC Classification:	311610
NAIC Description:	Animal Slaughtering and Processing

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1995-04-04
Company Identification Number:	1909742
Legal Registered Office Address:	9 FERN OVAL WEST Rockland ORANGEBURG United States of America (USA) 10962