PHILLIPS FEED SERVICE, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PHILLIPS FEED & PET SUPPLY BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2016 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total transfer of assets from this plan | 2016-12-31 | $1,978,858 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $82,107 |
| Total income from all sources (including contributions) | 2016-12-31 | $0 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $24,319 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $24,319 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $0 |
| Value of total assets at end of year | 2016-12-31 | $0 |
| Value of total assets at beginning of year | 2016-12-31 | $2,085,284 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $0 |
| Total interest from all sources | 2016-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $2,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $82,107 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $82,107 |
| Total non interest bearing cash at end of year | 2016-12-31 | $0 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $24,319 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $-24,319 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $2,003,177 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $1,978,858 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $1,978,858 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $24,319 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Did the plan have assets held for investment | 2016-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | Yes |
| 2015 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $82,107 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $79,353 |
| Total income from all sources (including contributions) | 2015-12-31 | $11,730,303 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $10,470,138 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $8,365,888 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $11,729,889 |
| Value of total assets at end of year | 2015-12-31 | $2,085,284 |
| Value of total assets at beginning of year | 2015-12-31 | $822,365 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $2,104,250 |
| Total interest from all sources | 2015-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $414 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $2,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $3,794,747 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2015-12-31 | $23,347 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $82,107 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $79,353 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2015-12-31 | $82,107 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2015-12-31 | $79,353 |
| Administrative expenses (other) incurred | 2015-12-31 | $1,316,735 |
| Total non interest bearing cash at end of year | 2015-12-31 | $24,319 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $0 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $1,260,165 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $2,003,177 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $743,012 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Investment advisory and management fees | 2015-12-31 | $750 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $1,978,858 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-12-31 | $743,012 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-12-31 | $743,012 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $1,358,217 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Assets. Invements in employer securities at end of year | 2015-12-31 | $0 |
| Assets. Invements in employer securities at beginning of year | 2015-12-31 | $0 |
| Contributions received in cash from employer | 2015-12-31 | $7,911,795 |
| Income. Dividends from common stock | 2015-12-31 | $414 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $7,007,671 |
| Contract administrator fees | 2015-12-31 | $786,765 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Disclaimer |
| Accountancy firm name | 2015-12-31 | TROUT, EBERSOLE & GROFF, LLP |
| Accountancy firm EIN | 2015-12-31 | 231551315 |
| 2014 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $79,353 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $32,054 |
| Total income from all sources (including contributions) | 2014-12-31 | $7,135,840 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $7,292,476 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $6,719,114 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $7,135,726 |
| Value of total assets at end of year | 2014-12-31 | $822,365 |
| Value of total assets at beginning of year | 2014-12-31 | $931,702 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $573,362 |
| Total interest from all sources | 2014-12-31 | $114 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Contributions received from participants | 2014-12-31 | $2,131,370 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2014-12-31 | $16,973 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-12-31 | $79,353 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-12-31 | $32,054 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-12-31 | $79,353 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-12-31 | $32,054 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $-156,636 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $743,012 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $899,648 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-12-31 | $743,012 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-12-31 | $899,648 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-12-31 | $899,648 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-12-31 | $114 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $1,779,115 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $4,987,383 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $4,939,999 |
| Contract administrator fees | 2014-12-31 | $573,362 |
| Did the plan have assets held for investment | 2014-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Disclaimer |
| Accountancy firm name | 2014-12-31 | TROUT, EBERSOLE & GROFF, LLP |
| Accountancy firm EIN | 2014-12-31 | 231551315 |
| 2013 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $32,054 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $73,996 |
| Total income from all sources (including contributions) | 2013-12-31 | $4,755,382 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $4,875,562 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $4,396,860 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $4,755,161 |
| Value of total assets at end of year | 2013-12-31 | $931,702 |
| Value of total assets at beginning of year | 2013-12-31 | $1,093,824 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $478,702 |
| Total interest from all sources | 2013-12-31 | $221 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2013-12-31 | Yes |
| Value of fidelity bond cover | 2013-12-31 | $500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Contributions received from participants | 2013-12-31 | $1,474,980 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2013-12-31 | $12,942 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-12-31 | $32,054 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-12-31 | $73,996 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-12-31 | $32,054 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-12-31 | $73,996 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $-120,180 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $899,648 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $1,019,828 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-12-31 | $899,648 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-12-31 | $1,019,828 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-12-31 | $1,019,828 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-12-31 | $221 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $1,341,897 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $3,267,239 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $3,054,963 |
| Contract administrator fees | 2013-12-31 | $478,702 |
| Did the plan have assets held for investment | 2013-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Disclaimer |
| Accountancy firm name | 2013-12-31 | TROUT, EBERSOLE & GROFF, LLP |
| Accountancy firm EIN | 2013-12-31 | 231551315 |
| 2012 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-12-31 | $0 |
| Total transfer of assets to this plan | 2012-12-31 | $210,062 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $73,996 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $40,594 |
| Total income from all sources (including contributions) | 2012-12-31 | $4,552,713 |
| Total loss/gain on sale of assets | 2012-12-31 | $0 |
| Total of all expenses incurred | 2012-12-31 | $3,742,987 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $3,355,356 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $4,552,487 |
| Value of total assets at end of year | 2012-12-31 | $1,093,824 |
| Value of total assets at beginning of year | 2012-12-31 | $40,634 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $387,631 |
| Total interest from all sources | 2012-12-31 | $226 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2012-12-31 | Yes |
| Value of fidelity bond cover | 2012-12-31 | $1,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Contributions received from participants | 2012-12-31 | $1,232,449 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2012-12-31 | $31,443 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-12-31 | $73,996 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-12-31 | $40,594 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-12-31 | $73,996 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-12-31 | $40,594 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $809,726 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $1,019,828 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $40 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-12-31 | $1,019,828 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-12-31 | $40 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-12-31 | $40 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-12-31 | $226 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $1,284,496 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $3,288,595 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $2,070,860 |
| Contract administrator fees | 2012-12-31 | $387,631 |
| Did the plan have assets held for investment | 2012-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Disclaimer |
| Accountancy firm name | 2012-12-31 | TROUT, EBERSOLE & GROFF, LLP |
| Accountancy firm EIN | 2012-12-31 | 231551315 |
| 2011 : PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $40,594 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $0 |
| Total income from all sources (including contributions) | 2011-12-31 | $3,571,384 |
| Total loss/gain on sale of assets | 2011-12-31 | $0 |
| Total of all expenses incurred | 2011-12-31 | $3,571,344 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $3,239,007 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $3,525,722 |
| Value of total assets at end of year | 2011-12-31 | $40,634 |
| Value of total assets at beginning of year | 2011-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $332,337 |
| Total interest from all sources | 2011-12-31 | $15 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2011-12-31 | Yes |
| Value of fidelity bond cover | 2011-12-31 | $500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Contributions received from participants | 2011-12-31 | $1,042,719 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2011-12-31 | $3,244 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $40,594 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-12-31 | $40,594 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-12-31 | $0 |
| Other income not declared elsewhere | 2011-12-31 | $45,647 |
| Administrative expenses (other) incurred | 2011-12-31 | $4,610 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $40 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $40 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Investment advisory and management fees | 2011-12-31 | $257 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $40 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $0 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $15 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $930,986 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $2,479,759 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $2,308,021 |
| Contract administrator fees | 2011-12-31 | $327,470 |
| Did the plan have assets held for investment | 2011-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Disclaimer |
| Accountancy firm name | 2011-12-31 | TROUT, EBERSOLE & GROFF, LLP |
| Accountancy firm EIN | 2011-12-31 | 231551315 |
| 2018: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – Trust | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement - Trust | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – Trust | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement - Trust | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – Trust | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement - Trust | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – Trust | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement - Trust | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – Trust | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement - Trust | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PHILLIPS FEED & PET SUPPLY BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008224337* |
| Policy instance | 4 |
| Insurance contract or identification number | 0008224337* | | Number of Individuals Covered | 227 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $5,327 | | 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 | | 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 $60,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,351 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30044509 |
| Policy instance | 3 |
| Insurance contract or identification number | 30044509 | | Number of Individuals Covered | 923 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,561 | | 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 | 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 $1,413 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632519* |
| Policy instance | 2 |
| Insurance contract or identification number | 632519* | | Number of Individuals Covered | 1295 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $42,337 | | Total amount of fees paid to insurance company | USD $6,693 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $667,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,243 | | Amount paid for insurance broker fees | 5147 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 1 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 1028 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 $695,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 1 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 1075 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $59,817 | | 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 $747,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,863 | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INS AND FINL SVCS |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632519* |
| Policy instance | 2 |
| Insurance contract or identification number | 632519* | | Number of Individuals Covered | 1310 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $38,614 | | Total amount of fees paid to insurance company | USD $4,093 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $588,901 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,614 | | Amount paid for insurance broker fees | 4093 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS AND FINL SVCS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30044509 |
| Policy instance | 3 |
| Insurance contract or identification number | 30044509 | | Number of Individuals Covered | 962 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,696 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,696 | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS AND FINANCIAL SVC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 819471 |
| Policy instance | 6 |
| Insurance contract or identification number | 819471 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $337 | | 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 | Yes | | 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 $993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $248 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INSURANCE & FINANCIAL |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 5 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 1072 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,936 | | 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 | 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 $173,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,107 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INSURANCE & FINANCIAL |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 4 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 543 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,432 | | 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 | 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 $129,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,301 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INSURANCE & FINANCIAL |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 3 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 1226 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,762 | | 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 | | 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 $180,706 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,755 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | CORNERSTONE INSURANCE & FINANCIAL |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 2 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 2075 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $44,827 | | 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 $747,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,827 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SERV |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30044509 |
| Policy instance | 1 |
| Insurance contract or identification number | 30044509 | | Number of Individuals Covered | 1020 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,975 | | 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 $126,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,975 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SERV. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 5 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,853 | | 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 | 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 $85,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,853 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SVCS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 4 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 845 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,024 | | 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 | 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 $107,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,024 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SVCS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 3 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 778 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,531 | | 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 | Yes | | 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 $115,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,531 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SVCS |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 2 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 768 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $21,841 | | 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 $437,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,841 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SVCS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30044509 |
| Policy instance | 1 |
| Insurance contract or identification number | 30044509 | | Number of Individuals Covered | 784 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,413 | | 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 $87,820 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,413 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MCCONKEY BENEFITS & FINANCIAL SVCS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02537348 |
| Policy instance | 2 |
| Insurance contract or identification number | 02537348 | | Number of Individuals Covered | 1211 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $759 | | 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 $38,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $759 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FINANCIAL SVCS |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | KBP |
| Policy instance | 1 |
| Insurance contract or identification number | KBP | | Number of Individuals Covered | 628 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 | | 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 $766,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 3 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 1252 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $18,801 | | 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 $313,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,801 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FINANCIAL SVCS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 4 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 706 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,383 | | 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 | 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 $223,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,383 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FIANCIAL SVCS. |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 15755 |
| Policy instance | 3 |
| Insurance contract or identification number | 15755 | | Number of Individuals Covered | 966 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $16,595 | | 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 $276,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,595 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FINANCIAL SVCS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 4 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 567 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $11,551 | | 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 | 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 $189,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,551 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FIANCIAL SVCS. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 2537355 |
| Policy instance | 2 |
| Insurance contract or identification number | 2537355 | | Number of Individuals Covered | 962 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $638 | | 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 $34,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $638 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | MC CONKEY BENEFITS & FINANCIAL SVCS |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | KBP |
| Policy instance | 1 |
| Insurance contract or identification number | KBP | | Number of Individuals Covered | 460 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 | | 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 $784,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-7162-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 057-7162-00 | | Number of Individuals Covered | 426 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,947 | | Total amount of fees paid to insurance company | USD $5,515 | | 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 $159,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 216680 |
| Policy instance | 4 |
| Insurance contract or identification number | 216680 | | Number of Individuals Covered | 523 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $13,082 | | 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 | 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 $159,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 2537360 |
| Policy instance | 2 |
| Insurance contract or identification number | 2537360 | | Number of Individuals Covered | 452 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $590 | | 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 $29,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | KBP |
| Policy instance | 1 |
| Insurance contract or identification number | KBP | | Number of Individuals Covered | 532 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 | | 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 $582,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 147055/147054 |
| Policy instance | 4 |
| Insurance contract or identification number | 147055/147054 | | Number of Individuals Covered | 317 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,697 | | Total amount of fees paid to insurance company | USD $618 | | 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 | | Other welfare benefits provided | AD&D AND LIFESTYLE LIFE & 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 $75,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,697 | | Amount paid for insurance broker fees | 618 | | Additional information about fees paid to insurance broker | SPECIAL PRODUCER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS GROUP, INC. |
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| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-7162-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 057-7162-00 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $4,472 | | Total amount of fees paid to insurance company | USD $2,241 | | 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 $160,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,472 | | Amount paid for insurance broker fees | 2241 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS GROUP, INC. |
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| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 2537355 |
| Policy instance | 2 |
| Insurance contract or identification number | 2537355 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $426 | | 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 $19,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $426 | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS GROUP, INC. |
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| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 500035 |
| Policy instance | 1 |
| Insurance contract or identification number | 500035 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $28,786 | | 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 | | 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 $2,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,786 | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS GROUP, INC. |
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