401k Plan data: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN plan

SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 401k Plan overview

Plan Name	SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN
Plan identification number	505

SOUTHERN JERSEY FAMILY MEDICAL CENTERS 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

SOUTHERN JERSEY FAMILY MEDICAL CENTERS has sponsored the creation of one or more 401k plans.

Company Name: SOUTHERN JERSEY FAMILY MEDICAL CENTERS

Employer identification number (EIN): 222159336

NAIC Classification: 621399
NAIC Description: Offices of All Other Miscellaneous Health Practitioners

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2021-07-01 LINDA Y. FLAKE 2023-03-28
505 2020-07-01 LINDA Y. FLAKE 2022-04-07
505 2019-07-01 LINDA Y. FLAKE 2021-01-13
505 2018-07-01 KRISTA GROSS 2019-11-26
505 2017-07-01 KRISTA GROSS 2019-03-28
505 2016-07-01
505 2015-07-01 LINDA Y FLAKE
505 2014-07-01 LINDA Y FLAKE
505 2013-07-01 LINDA FLAKE
505 2012-07-01 LINDA FLAKE
505 2011-07-01 LINDA FLAKE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
505	2021-07-01	LINDA Y. FLAKE	2023-03-28
505	2020-07-01	LINDA Y. FLAKE	2022-04-07
505	2019-07-01	LINDA Y. FLAKE	2021-01-13
505	2018-07-01	KRISTA GROSS	2019-11-26
505	2017-07-01	KRISTA GROSS	2019-03-28
505	2016-07-01
505	2015-07-01	LINDA Y FLAKE
505	2014-07-01	LINDA Y FLAKE
505	2013-07-01	LINDA FLAKE
505	2012-07-01	LINDA FLAKE
505	2011-07-01	LINDA FLAKE

Plan Statistics for SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN

401k plan membership statisitcs for SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN

Measure Date Value
2021: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 177
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 126
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 126
2020: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 207
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 157
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 157
2019: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 209
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 206
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 206
2018: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 216
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 213
Number of retired or separated participants receiving benefits 2018-07-01 0
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 213
Number of employers contributing to the scheme 2018-07-01 0
2017: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 216
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 192
Number of retired or separated participants receiving benefits 2017-07-01 0
Number of other retired or separated participants entitled to future benefits 2017-07-01 0
Total of all active and inactive participants 2017-07-01 192
Number of employers contributing to the scheme 2017-07-01 0
2016: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 201
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 216
Number of retired or separated participants receiving benefits 2016-07-01 0
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 216
2015: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 193
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 192
Number of retired or separated participants receiving benefits 2015-07-01 0
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 192
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-07-01 0
2014: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 182
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 181
Number of retired or separated participants receiving benefits 2014-07-01 0
Number of other retired or separated participants entitled to future benefits 2014-07-01 0
Total of all active and inactive participants 2014-07-01 181
2013: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 178
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 182
Number of retired or separated participants receiving benefits 2013-07-01 0
Number of other retired or separated participants entitled to future benefits 2013-07-01 0
Total of all active and inactive participants 2013-07-01 182
2012: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 188
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 186
Number of retired or separated participants receiving benefits 2012-07-01 0
Number of other retired or separated participants entitled to future benefits 2012-07-01 0
Total of all active and inactive participants 2012-07-01 186
2011: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 178
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 183
Number of retired or separated participants receiving benefits 2011-07-01 1
Number of other retired or separated participants entitled to future benefits 2011-07-01 0
Total of all active and inactive participants 2011-07-01 184

Measure	Date	Value
2021: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	177
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	126
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	126
2020: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	207
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	157
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	157
2019: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	209
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	206
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	206
2018: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	216
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	213
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	213
Number of employers contributing to the scheme	2018-07-01	0
2017: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	216
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	192
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	192
Number of employers contributing to the scheme	2017-07-01	0
2016: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	201
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	216
Number of retired or separated participants receiving benefits	2016-07-01	0
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	216
2015: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	193
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	192
Number of retired or separated participants receiving benefits	2015-07-01	0
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	192
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-07-01	0
2014: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	182
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	181
Number of retired or separated participants receiving benefits	2014-07-01	0
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	181
2013: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	178
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	182
Number of retired or separated participants receiving benefits	2013-07-01	0
Number of other retired or separated participants entitled to future benefits	2013-07-01	0
Total of all active and inactive participants	2013-07-01	182
2012: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	188
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	186
Number of retired or separated participants receiving benefits	2012-07-01	0
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	186
2011: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	178
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	183
Number of retired or separated participants receiving benefits	2011-07-01	1
Number of other retired or separated participants entitled to future benefits	2011-07-01	0
Total of all active and inactive participants	2011-07-01	184

Form 5500 Responses for SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN

2021: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Submission has been amended	No
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: SOUTHERN JERSEY FAMILY MEDICAL CENTERS BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	Yes
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100 0001

Policy instance

Insurance contract or identification number	907100 0001
Number of Individuals Covered	18
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,717
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,717
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	135
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $841
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $841
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

LCT38

Policy instance

Insurance contract or identification number	LCT38
Number of Individuals Covered	70
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $6,374
Total amount of fees paid to insurance company	USD $82
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, CANCER
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $55,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,573
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

0000844661

Policy instance

Insurance contract or identification number	0000844661
Number of Individuals Covered	259
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $126,463
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126,463
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	70
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,400
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $31,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,400
Insurance broker organization code?	3

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	78
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $2,254
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $51,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,254
Insurance broker organization code?	3

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

Policy contract number

759352

Policy instance

Insurance contract or identification number	759352
Number of Individuals Covered	155
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $9,049
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,049
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008742240

Policy instance

Insurance contract or identification number	0008742240
Number of Individuals Covered	30
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $230
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $230
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

LCT38

Policy instance

Insurance contract or identification number	LCT38
Number of Individuals Covered	50
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $9,309
Total amount of fees paid to insurance company	USD $497
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, CANCER
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $58,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,788
Amount paid for insurance broker fees	69
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

0000844661

Policy instance

Insurance contract or identification number	0000844661
Number of Individuals Covered	251
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $128,324
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $128,324
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	66
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,672
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $38,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,672
Insurance broker organization code?	3

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	75
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $2,220
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $51,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,220
Insurance broker organization code?	3

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

Policy contract number

759352

Policy instance

Insurance contract or identification number	759352
Number of Individuals Covered	180
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $12,736
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,736
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100 0001

Policy instance

Insurance contract or identification number	907100 0001
Number of Individuals Covered	18
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $3,561
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,561
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008742240

Policy instance

Insurance contract or identification number	0008742240
Number of Individuals Covered	31
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $243
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $243
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	139
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $820
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $820
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008742240

Policy instance

Insurance contract or identification number	0008742240
Number of Individuals Covered	33
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $257
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $257
Insurance broker organization code?	3

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

Policy contract number

759352

Policy instance

Insurance contract or identification number	759352
Number of Individuals Covered	207
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	79
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,386
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $57,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,386
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	83
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,998
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $48,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,998
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

768280G

Policy instance

Insurance contract or identification number	768280G
Number of Individuals Covered	206
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $15,211
Total amount of fees paid to insurance company	USD $7,701
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $127,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,211
Amount paid for insurance broker fees	7701
Additional information about fees paid to insurance broker	FEES BONUS
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

768280G

Policy instance

Insurance contract or identification number	1051061
Number of Individuals Covered	1458
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $30,140
Total amount of fees paid to insurance company	USD $15,969
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $432,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,140
Amount paid for insurance broker fees	15969
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

0000844661

Policy instance

Insurance contract or identification number	0000844661
Number of Individuals Covered	283
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $150,054
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $150,054
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100 0001

Policy instance

Insurance contract or identification number	907100 0001
Number of Individuals Covered	21
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,540
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,540
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	164
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $896
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $896
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

LCT38

Policy instance

Insurance contract or identification number	LCT38
Number of Individuals Covered	67
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $13,631
Total amount of fees paid to insurance company	USD $631
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, CANCER
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $58,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,122
Amount paid for insurance broker fees	144
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

LCT38

Policy instance

Insurance contract or identification number	LCT38
Number of Individuals Covered	65
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $17,900
Total amount of fees paid to insurance company	USD $1,130
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $47,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,815
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

768280G

Policy instance

Insurance contract or identification number	768280G
Number of Individuals Covered	170
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $11,542
Total amount of fees paid to insurance company	USD $5,079
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $97,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,542
Amount paid for insurance broker fees	5079
Additional information about fees paid to insurance broker	FEES BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100

Policy instance

Insurance contract or identification number	907100
Number of Individuals Covered	27
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $3,999
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $21,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,999
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

844661

Policy instance

Insurance contract or identification number	844661
Number of Individuals Covered	307
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $153,572
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153,572
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	175
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $961
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $961
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	42
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $302
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $11,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $302
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	98
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $2,324
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,324
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

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	78
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $2,113
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,113
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	162
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $871
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907447

Policy instance

Insurance contract or identification number	907447
Number of Individuals Covered	41
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,418
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

844661

Policy instance

Insurance contract or identification number	844661
Number of Individuals Covered	282
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $143,707
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	71
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,680
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

768280G

Policy instance

Insurance contract or identification number	768280G
Number of Individuals Covered	207
Insurance policy start date	2016-10-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $13,025
Total amount of fees paid to insurance company	USD $11,559
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $107,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHCARE DENTAL, INC. (National Association of Insurance Commissioners NAIC id number: 11146 )

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	94
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $2,458
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	77
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $455
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $16,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100

Policy instance

Insurance contract or identification number	907100
Number of Individuals Covered	34
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $4,036
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $20,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

844661

Policy instance

Insurance contract or identification number	844661
Number of Individuals Covered	259
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $113,965
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $113,965
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	161
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $3,832
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $88,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,832
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	147
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $817
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $817
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	188
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $16,152
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $151,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,152
Insurance broker organization code?	3
Insurance broker name	JOHN ROBER, GERARD

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	127
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $3,925
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,925
Insurance broker organization code?	3
Insurance broker name	JOHN ROBERT GERARD

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	181
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $14,395
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $128,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,395
Insurance broker organization code?	3
Insurance broker name	JOHN ROBERT GERARD

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	152
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $4,209
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $93,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,209
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	127
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $2,440
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,440
Insurance broker organization code?	3
Insurance broker name	JOHN ROBERT GERARD

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

Policy contract number

86543

Policy instance

Insurance contract or identification number	86543
Number of Individuals Covered	132
Insurance policy start date	2014-07-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $64,053
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,729,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,053
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30056304

Policy instance

Insurance contract or identification number	30056304
Number of Individuals Covered	145
Insurance policy start date	2015-04-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $310
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $310
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

HORIZON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14690 )

Policy contract number

86543

Policy instance

Insurance contract or identification number	86543
Number of Individuals Covered	136
Insurance policy start date	2014-07-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $890
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $890
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

AMERIHEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60061 )

Policy contract number

844661

Policy instance

Insurance contract or identification number	844661
Number of Individuals Covered	251
Insurance policy start date	2015-04-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $29,968
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,968
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	100
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,727
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,727
Insurance broker organization code?	3
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	REFERRAL/SERVICE FEE
Insurance broker name	JOHN ROBERT GERARD

HORIZON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14690 )

Policy contract number

86543

Policy instance

Insurance contract or identification number	86543
Number of Individuals Covered	145
Insurance policy start date	2014-04-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $296
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

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

Policy contract number

86543/96431

Policy instance

Insurance contract or identification number	86543/96431
Number of Individuals Covered	178
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $87,951
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,230,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,951
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	182
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $12,415
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $114,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,415
Insurance broker organization code?	3
Insurance broker name	JOHN ROBERT GERARD

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	179
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,084
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $66,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,084
Insurance broker organization code?	3
Insurance broker name	GERARD, JOHN, ROBERT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907447

Policy instance

Insurance contract or identification number	907447
Number of Individuals Covered	80
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,462
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFESTYLE LIFE AND AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,462
Insurance broker organization code?	3
Insurance broker name	JOHN R GERARD

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008742240

Policy instance

Insurance contract or identification number	0008742240
Number of Individuals Covered	55
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $422
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Insurance broker organization code?	3
Insurance broker name	JOHN R GERARD

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

Policy contract number

86543

Policy instance

Insurance contract or identification number	86543
Number of Individuals Covered	130
Insurance policy start date	2013-04-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $21,249
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $538,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,249
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

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

Policy contract number

096431

Policy instance

Insurance contract or identification number	096431
Number of Individuals Covered	150
Insurance policy start date	2012-04-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,217
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,217
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

280972

Policy instance

Insurance contract or identification number	280972
Number of Individuals Covered	264
Insurance policy start date	2012-01-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $43,462
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,462
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	177
Insurance policy start date	2012-02-28
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,192
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,192
Insurance broker organization code?	3
Insurance broker name	GERARD, JOHN, ROBERT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100

Policy instance

Insurance contract or identification number	907100
Number of Individuals Covered	25
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,226
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,226
Insurance broker organization code?	3
Insurance broker name	JOHN R GERARD

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

280972

Policy instance

Insurance contract or identification number	280972
Number of Individuals Covered	243
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $62,629
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,629
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

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

Policy contract number

96431

Policy instance

Insurance contract or identification number	96431
Number of Individuals Covered	150
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,022
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $94,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,022
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

8742240

Policy instance

Insurance contract or identification number	8742240
Number of Individuals Covered	43
Insurance policy start date	2013-02-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $124
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $124
Insurance broker organization code?	3
Insurance broker name	JOHN R GERARD

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0261818

Policy instance

Insurance contract or identification number	R0261818
Number of Individuals Covered	177
Insurance policy start date	2011-02-28
Insurance policy end date	2012-02-27
Total amount of commissions paid to insurance broker	USD $5,943
Total amount of fees paid to insurance company	USD $253
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $70,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008742240

Policy instance

Insurance contract or identification number	0008742240
Number of Individuals Covered	63
Insurance policy start date	2011-02-28
Insurance policy end date	2012-02-28
Total amount of commissions paid to insurance broker	USD $4,673
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

280972

Policy instance

Insurance contract or identification number	280972
Number of Individuals Covered	237
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $85,582
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907100

Policy instance

Insurance contract or identification number	907100
Number of Individuals Covered	25
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,982
Total amount of fees paid to insurance company	USD $66
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

096431

Policy instance

Insurance contract or identification number	096431
Number of Individuals Covered	149
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,530
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $81,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

907447

Policy instance

Insurance contract or identification number	907447
Number of Individuals Covered	76
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,571
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LIFESTYLE LIFE AND ADD
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SOUTHERN JERSEY FAMILY MEDICAL CENTERS
Employer identification number (EIN):	222159336
NAIC Classification:	621399
NAIC Description:	Offices of All Other Miscellaneous Health Practitioners