401k Plan data: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN plan

SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN
Plan identification number	501

SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SOLAR ATMOSPHERES, INC. has sponsored the creation of one or more 401k plans.

Company Name: SOLAR ATMOSPHERES, INC.

Employer identification number (EIN): 232363698

NAIC Classification: 332810

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2018-10-31
501 2016-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2017-07-31
501 2015-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2016-10-14
501 2014-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2015-09-30
501 2013-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2014-10-15
501 2012-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2013-07-22
501 2011-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2012-10-05
501 2010-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2011-09-27
501 2009-01-01 SUSAN M WOLSKE G. SCOTT JACOBY 2010-10-14

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2018-10-31
501	2016-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2017-07-31
501	2015-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2016-10-14
501	2014-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2015-09-30
501	2013-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2014-10-15
501	2012-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2013-07-22
501	2011-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2012-10-05
501	2010-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2011-09-27
501	2009-01-01	SUSAN M WOLSKE	G. SCOTT JACOBY	2010-10-14

Plan Statistics for SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 255
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 278
Total of all active and inactive participants 2022-01-01 278
2021: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 281
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 255
Total of all active and inactive participants 2021-01-01 255
2020: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 281
Total of all active and inactive participants 2020-01-01 281
2019: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 242
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 273
Total of all active and inactive participants 2019-01-01 273
2018: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 242
Total of all active and inactive participants 2018-01-01 242
2017: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 230
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 229
Total of all active and inactive participants 2017-01-01 229
2016: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 211
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 230
Total of all active and inactive participants 2016-01-01 230
2015: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 211
Total of all active and inactive participants 2015-01-01 211
2014: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 290
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 201
Total of all active and inactive participants 2014-01-01 201
2013: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 292
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 290
Total of all active and inactive participants 2013-01-01 290
2012: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 284
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 292
Total of all active and inactive participants 2012-01-01 292
2011: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 288
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 284
Total of all active and inactive participants 2011-01-01 284
2010: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 288
Total of all active and inactive participants 2010-01-01 288
2009: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 277
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 293
Total of all active and inactive participants 2009-01-01 293

Measure	Date	Value
2022: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	255
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	278
Total of all active and inactive participants	2022-01-01	278
2021: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	281
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	255
Total of all active and inactive participants	2021-01-01	255
2020: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	281
Total of all active and inactive participants	2020-01-01	281
2019: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	242
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	273
Total of all active and inactive participants	2019-01-01	273
2018: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	242
Total of all active and inactive participants	2018-01-01	242
2017: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	230
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	229
Total of all active and inactive participants	2017-01-01	229
2016: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	211
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	230
Total of all active and inactive participants	2016-01-01	230
2015: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	211
Total of all active and inactive participants	2015-01-01	211
2014: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	290
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	201
Total of all active and inactive participants	2014-01-01	201
2013: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	292
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	290
Total of all active and inactive participants	2013-01-01	290
2012: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	284
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	292
Total of all active and inactive participants	2012-01-01	292
2011: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	288
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	284
Total of all active and inactive participants	2011-01-01	284
2010: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	288
Total of all active and inactive participants	2010-01-01	288
2009: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	277
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	293
Total of all active and inactive participants	2009-01-01	293

Form 5500 Responses for SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN

2022: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: SOLAR ATMOSPHERES, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	278
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $4,212
Total amount of fees paid to insurance company	USD $7,051
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,212
Amount paid for insurance broker fees	7051
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	201
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $61,576
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,576
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	315
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $5,766
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,766
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	278
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $5,416
Total amount of fees paid to insurance company	USD $14,053
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,416
Amount paid for insurance broker fees	14053
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	249
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $7,907
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,907
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	297
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $30,140
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,601,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,140
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	293
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	307
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $2,938
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,938
Insurance broker organization code?	3

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	117
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $28,403
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,403
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	278
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $12,236
Total amount of fees paid to insurance company	USD $14,722
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,236
Amount paid for insurance broker fees	14722
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	255
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $4,138
Total amount of fees paid to insurance company	USD $7,248
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,138
Amount paid for insurance broker fees	7248
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	255
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $5,357
Total amount of fees paid to insurance company	USD $14,548
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,357
Amount paid for insurance broker fees	14548
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	339
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $5,669
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $135,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,669
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	204
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $56,310
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,310
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	228
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $7,950
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,950
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	231
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $28,050
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,370,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,050
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	231
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	312
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,020
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,020
Insurance broker organization code?	3

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	117
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $28,024
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,024
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	255
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $11,583
Total amount of fees paid to insurance company	USD $15,177
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,583
Amount paid for insurance broker fees	15177
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Number of Individuals Covered	255
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	281
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $4,241
Total amount of fees paid to insurance company	USD $6,676
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,241
Amount paid for insurance broker fees	6676
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	281
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $5,451
Total amount of fees paid to insurance company	USD $13,404
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,451
Amount paid for insurance broker fees	13404
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	360
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $5,749
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,749
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	214
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $65,444
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,444
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	265
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $27,214
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,396,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,214
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	262
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	263
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $8,036
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,036
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Number of Individuals Covered	281
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	281
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $12,482
Total amount of fees paid to insurance company	USD $13,738
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,482
Amount paid for insurance broker fees	13738
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	125
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $33,028
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,028
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	341
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $651
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $651
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	217
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $91,975
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,975
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	347
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $5,090
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,090
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	273
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $5,292
Total amount of fees paid to insurance company	USD $12,309
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,292
Amount paid for insurance broker fees	12309
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	273
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $4,049
Total amount of fees paid to insurance company	USD $6,135
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,049
Amount paid for insurance broker fees	6135
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	230
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,874
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,874
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	228
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $23,760
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,249,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,760
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	229
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Number of Individuals Covered	270
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	273
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $10,549
Total amount of fees paid to insurance company	USD $12,487
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,549
Amount paid for insurance broker fees	12487
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	111
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $34,115
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,115
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	325
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,382
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,382
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	219
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $88,919
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88,919
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	324
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $4,648
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,648
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	242
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $5,260
Total amount of fees paid to insurance company	USD $10,785
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,260
Amount paid for insurance broker fees	10785
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	242
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $4,007
Total amount of fees paid to insurance company	USD $5,373
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,007
Amount paid for insurance broker fees	5373
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	185
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $6,652
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,652

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	212
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $21,362
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,130,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,362
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	215
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	309
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $693
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $693
Insurance broker organization code?	3

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	94
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $24,076
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,076
Insurance broker organization code?	3

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	242
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $10,252
Total amount of fees paid to insurance company	USD $10,931
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,252
Amount paid for insurance broker fees	10931
Additional information about fees paid to insurance broker	OTHER COMP
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Number of Individuals Covered	240
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099078127

Policy instance

Insurance contract or identification number	000099078127
Number of Individuals Covered	230
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	CHUBB AND SON, A DIVISION OF FEDERA

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	229
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $9,633
Total amount of fees paid to insurance company	USD $9,257
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,633
Amount paid for insurance broker fees	9257
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	75
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $23,010
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,010
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	298
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,253
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,253
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	227
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $80,361
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80,361
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	322
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $4,561
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,561
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	229
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $5,132
Total amount of fees paid to insurance company	USD $8,864
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,132
Amount paid for insurance broker fees	8864
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	229
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $3,873
Total amount of fees paid to insurance company	USD $4,425
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,873
Amount paid for insurance broker fees	4425
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	173
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $5,862
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,862
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	176
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $19,866
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $990,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,866
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	179
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	77
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,912
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,912
Insurance broker name	EMERSON REID DBA TRA BENEFIT

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	318
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $721
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $721
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	177
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	173
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $18,480
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $987,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,480
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	153
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $5,416
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,416
Insurance broker name	FOUR M CONSULTING INC

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	202
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $4,795
Total amount of fees paid to insurance company	USD $4,332
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,795
Amount paid for insurance broker fees	4332
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0772730

Policy instance

Insurance contract or identification number	0772730
Number of Individuals Covered	315
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $3,916
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,916
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	245
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $71,292
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,292
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

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

Policy contract number

G000ATZB

Policy instance

Insurance contract or identification number	G000ATZB
Number of Individuals Covered	202
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $3,555
Total amount of fees paid to insurance company	USD $2,177
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,555
Amount paid for insurance broker fees	2177
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	74
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $792
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $792
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	256
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $65,254
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,254
Insurance broker organization code?	3
Insurance broker name	EMERSON REID DBA TRA BENEFIT

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

0000076151

Policy instance

Insurance contract or identification number	0000076151
Number of Individuals Covered	329
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
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

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	141
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $13,660
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $405,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,660
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

062350

Policy instance

Insurance contract or identification number	062350
Number of Individuals Covered	109
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $209
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	98
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,482
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,482
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	204
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $5,585
Total amount of fees paid to insurance company	USD $29
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,585
Amount paid for insurance broker fees	29
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	204
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $3,536
Total amount of fees paid to insurance company	USD $57
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,536
Amount paid for insurance broker fees	57
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

010-039253

Policy instance

Insurance contract or identification number	010-039253
Number of Individuals Covered	340
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $2,920
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 )

Policy contract number

US00640C

Policy instance

Insurance contract or identification number	US00640C
Number of Individuals Covered	290
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $69,712
Total amount of fees paid to insurance company	USD $6,470
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,449,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,712
Amount paid for insurance broker fees	6470
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

010-039253

Policy instance

Insurance contract or identification number	010-039253
Number of Individuals Covered	329
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $2,865
Total amount of fees paid to insurance company	USD $1,990
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,865
Amount paid for insurance broker fees	1990
Insurance broker name	FOUR M CONSULTING INC

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	186
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $3,536
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,536
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	186
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $5,571
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,571
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

ABL663864

Policy instance

Insurance contract or identification number	ABL663864
Number of Individuals Covered	100
Insurance policy start date	2012-06-04
Insurance policy end date	2013-06-04
Total amount of commissions paid to insurance broker	USD $724
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $724
Insurance broker organization code?	3
Insurance broker name	WILLIAM J. KEATON

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	98
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $3,482
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,482
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	109
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $209
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

04723481

Policy instance

Insurance contract or identification number	04723481
Number of Individuals Covered	141
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $13,660
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $405,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,660
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

659351

Policy instance

Insurance contract or identification number	659351
Number of Individuals Covered	292
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $4,574
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,574
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	179
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $3,368
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,368
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	179
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $4,931
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,931
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

ABL663864

Policy instance

Insurance contract or identification number	ABL663864
Number of Individuals Covered	100
Insurance policy start date	2011-06-04
Insurance policy end date	2012-06-04
Total amount of commissions paid to insurance broker	USD $725
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $725
Insurance broker organization code?	3
Insurance broker name	WILLIAM J. KEATON

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	91
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,947
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,947
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	95
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $9,009
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $278,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,009
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 )

Policy contract number

US00640C

Policy instance

Insurance contract or identification number	US00640C
Number of Individuals Covered	290
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $69,712
Total amount of fees paid to insurance company	USD $6,470
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,449,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,712
Insurance broker organization code?	3
Amount paid for insurance broker fees	6470
Insurance broker name	UNIVEST INSURANCE INC.

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	96
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $155
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 )

Policy contract number

US00640C

Policy instance

Insurance contract or identification number	US00640C
Number of Individuals Covered	284
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $70,419
Total amount of fees paid to insurance company	USD $6,402
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,550,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	169
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $4,577
Total amount of fees paid to insurance company	USD $284
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,512
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

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	93
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $133
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	92
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $8,999
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $255,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	100
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $3,100
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ABL663864

Policy instance

Insurance contract or identification number	ABL663864
Number of Individuals Covered	100
Insurance policy start date	2010-06-04
Insurance policy end date	2011-06-04
Total amount of commissions paid to insurance broker	USD $725
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

659351

Policy instance

Insurance contract or identification number	659351
Number of Individuals Covered	282
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $4,466
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	169
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Total amount of commissions paid to insurance broker	USD $3,121
Total amount of fees paid to insurance company	USD $477
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 )

Policy contract number

US00640C

Policy instance

Insurance contract or identification number	US00640C
Number of Individuals Covered	288
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $72,448
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,459,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,448
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	160
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $3,041
Total amount of fees paid to insurance company	USD $93
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,041
Amount paid for insurance broker fees	93
Additional information about fees paid to insurance broker	PRIOR YEAR COMMISSIONS PAID
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

659351

Policy instance

Insurance contract or identification number	659351
Number of Individuals Covered	280
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $4,520
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,520
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

5447918

Policy instance

Insurance contract or identification number	5447918
Number of Individuals Covered	160
Insurance policy start date	2009-12-01
Insurance policy end date	2010-11-30
Total amount of commissions paid to insurance broker	USD $4,284
Total amount of fees paid to insurance company	USD $83
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,284
Amount paid for insurance broker fees	83
Additional information about fees paid to insurance broker	PRIOR YEAR COMMISSIONS PAID
Insurance broker organization code?	3
Insurance broker name	UNIVEST INSURANCE INC.

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

Policy contract number

ABL663864

Policy instance

Insurance contract or identification number	ABL663864
Number of Individuals Covered	100
Insurance policy start date	2009-06-04
Insurance policy end date	2010-06-04
Total amount of commissions paid to insurance broker	USD $725
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $725
Insurance broker organization code?	3
Insurance broker name	WILLIAM J. KEATON

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

259855-000

Policy instance

Insurance contract or identification number	259855-000
Number of Individuals Covered	103
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $3,173
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,173
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	103
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $194
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $194
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 )

Policy contract number

01324945

Policy instance

Insurance contract or identification number	01324945
Number of Individuals Covered	103
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $10,396
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $290,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,396
Insurance broker organization code?	3
Insurance broker name	FOUR M CONSULTING INC

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Company Name:	SOLAR ATMOSPHERES, INC.
Employer identification number (EIN):	232363698
NAIC Classification:	332810