401k Plan data: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN plan

SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN
Plan identification number	501

SICOM SYSTEMS HEALTH & 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) Other welfare benefit cover

401k Sponsoring company profile

SICOM SYSTEMS, INC. has sponsored the creation of one or more 401k plans.

Company Name: SICOM SYSTEMS, INC.

Employer identification number (EIN): 232480489

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01 KELLEY TORPEY 2020-07-17
501 2018-01-01 JOHN LUDROF 2019-10-07
501 2018-01-01 JOHN LUDROF 2019-10-07
501 2018-01-01 JOHN LUDROF 2019-10-07
501 2017-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01 LINDA STONE
501 2014-01-01 LINDA STONE
501 2014-01-01 LINDA STONE LINDA STONE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-01-01	KELLEY TORPEY	2020-07-17
501	2018-01-01			JOHN LUDROF	2019-10-07
501	2018-01-01			JOHN LUDROF	2019-10-07
501	2018-01-01	JOHN LUDROF	2019-10-07
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01	LINDA STONE
501	2014-01-01	LINDA STONE
501	2014-01-01	LINDA STONE		LINDA STONE

Plan Statistics for SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2019: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 387
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
2018: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 316
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 387
Total of all active and inactive participants 2018-01-01 387
2017: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 203
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 316
Total of all active and inactive participants 2017-01-01 316
2016: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 206
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 203
Total of all active and inactive participants 2016-01-01 203
2015: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 206
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 206
2014: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 200
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 200

Measure	Date	Value
2019: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	387
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
2018: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	316
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	387
Total of all active and inactive participants	2018-01-01	387
2017: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	203
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	316
Total of all active and inactive participants	2017-01-01	316
2016: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	206
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	203
Total of all active and inactive participants	2016-01-01	203
2015: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	206
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	206
2014: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	200
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	200

Form 5500 Responses for SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN

2019: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SICOM SYSTEMS HEALTH & 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: SICOM SYSTEMS HEALTH & 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: SICOM SYSTEMS HEALTH & WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	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

GLTD0AVYW

Policy instance

Insurance contract or identification number	GLTD0AVYW
Number of Individuals Covered	333
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,417
Total amount of fees paid to insurance company	USD $1,372
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,417
Amount paid for insurance broker fees	1372
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

685441

Policy instance

Insurance contract or identification number	685441
Number of Individuals Covered	305
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,675
Total amount of fees paid to insurance company	USD $1,148
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,675
Amount paid for insurance broker fees	1148
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

GUG0AVYW

Policy instance

Insurance contract or identification number	GUG0AVYW
Number of Individuals Covered	333
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,436
Total amount of fees paid to insurance company	USD $2,514
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $49,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,436
Amount paid for insurance broker fees	2514
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

GLUG0AVYW

Policy instance

Insurance contract or identification number	GLUG0AVYW
Number of Individuals Covered	326
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,171
Total amount of fees paid to insurance company	USD $1,206
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,171
Amount paid for insurance broker fees	1206
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

GVTL0AVYW

Policy instance

Insurance contract or identification number	GVTL0AVYW
Number of Individuals Covered	123
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,350
Total amount of fees paid to insurance company	USD $1,101
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,350
Amount paid for insurance broker fees	1101
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	7

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	5
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $71
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36
Insurance broker organization code?	3

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

Policy contract number

R0093120

Policy instance

Insurance contract or identification number	R0093120
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $30
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $304
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
Insurance broker organization code?	3

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

Policy contract number

R0093120

Policy instance

Insurance contract or identification number	R0093120
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $62
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

685441

Policy instance

Insurance contract or identification number	685441
Number of Individuals Covered	312
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,052
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $141,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,052
Insurance broker organization code?	3

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $78
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Insurance broker organization code?	3

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

Policy contract number

GVTL0AVYW

Policy instance

Insurance contract or identification number	GVTL0AVYW
Number of Individuals Covered	107
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,670
Total amount of fees paid to insurance company	USD $571
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $24,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,670
Amount paid for insurance broker fees	571
Insurance broker organization code?	7

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

Policy contract number

GLUG0AVYW

Policy instance

Insurance contract or identification number	GLUG0AVYW
Number of Individuals Covered	358
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,278
Total amount of fees paid to insurance company	USD $838
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $26,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,278
Amount paid for insurance broker fees	838
Insurance broker organization code?	3

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

Policy contract number

GUG0AVYW

Policy instance

Insurance contract or identification number	GUG0AVYW
Number of Individuals Covered	387
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,027
Total amount of fees paid to insurance company	USD $1,710
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,027
Amount paid for insurance broker fees	1710
Insurance broker organization code?	3

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

Policy contract number

GLTD0AVYW

Policy instance

Insurance contract or identification number	GLTD0AVYW
Number of Individuals Covered	387
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,631
Total amount of fees paid to insurance company	USD $962
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,631
Amount paid for insurance broker fees	962
Insurance broker organization code?	3

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

Policy contract number

0865473HNO

Policy instance

Insurance contract or identification number	0865473HNO
Number of Individuals Covered	302
Insurance policy start date	2016-02-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $59,054
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,055,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,054
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

685441

Policy instance

Insurance contract or identification number	685441
Number of Individuals Covered	286
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,397
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,397
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

GLTD0AVYW

Policy instance

Insurance contract or identification number	GLTD0AVYW
Number of Individuals Covered	316
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,945
Total amount of fees paid to insurance company	USD $528
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $21,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,945
Amount paid for insurance broker fees	528
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

GUG0AVYW

Policy instance

Insurance contract or identification number	GUG0AVYW
Number of Individuals Covered	316
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,439
Total amount of fees paid to insurance company	USD $700
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,439
Amount paid for insurance broker fees	700
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

GLUG0AVYW

Policy instance

Insurance contract or identification number	GLUG0AVYW
Number of Individuals Covered	316
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,603
Total amount of fees paid to insurance company	USD $468
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,603
Amount paid for insurance broker fees	468
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

GVTL0AVYW

Policy instance

Insurance contract or identification number	GVTL0AVYW
Number of Individuals Covered	60
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,902
Total amount of fees paid to insurance company	USD $262
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,902
Amount paid for insurance broker fees	262
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	7
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $100
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52
Insurance broker organization code?	3
Insurance broker name	MARK JACOB RIEDER

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

Policy contract number

R0093120

Policy instance

Insurance contract or identification number	R0093120
Number of Individuals Covered	3
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

0865473

Policy instance

Insurance contract or identification number	0865473
Number of Individuals Covered	14
Insurance policy start date	2016-02-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $2,514
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,514
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SVCS INC

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

Policy contract number

135707

Policy instance

Insurance contract or identification number	135707
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-02-01
Total amount of commissions paid to insurance broker	USD $47
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERV

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

Policy contract number

GVTL0AVYW

Policy instance

Insurance contract or identification number	GVTL0AVYW
Number of Individuals Covered	26
Insurance policy start date	2015-02-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $614
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $445
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

GUG0AVYW

Policy instance

Insurance contract or identification number	GUG0AVYW
Number of Individuals Covered	178
Insurance policy start date	2015-02-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,665
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $930
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING

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

Policy contract number

0865473HNO

Policy instance

Insurance contract or identification number	0865473HNO
Number of Individuals Covered	206
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Welfare Benefit Premiums Paid to Carrier	USD $828,130
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

0865473

Policy instance

Insurance contract or identification number	0865473
Number of Individuals Covered	11
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

591029

Policy instance

Insurance contract or identification number	591029
Number of Individuals Covered	153
Insurance policy start date	2015-01-01
Insurance policy end date	2015-02-01
Total amount of commissions paid to insurance broker	USD $287
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $2,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287
Insurance broker name	CBIZ BENEFITS & INSURANCE SERV

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	29
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,252
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $738
Insurance broker organization code?	3
Insurance broker name	CBIZ BENEFITS & INSURANCE SERVICES

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

Policy contract number

R0093120

Policy instance

Insurance contract or identification number	R0093120
Number of Individuals Covered	6
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $532
Other welfare benefits provided	GCI
Welfare Benefit Premiums Paid to Carrier	USD $1,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $213
Insurance broker organization code?	3
Insurance broker name	ADVANCED BENEFITS COMMUNICATION LLC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

685441

Policy instance

Insurance contract or identification number	685441
Number of Individuals Covered	152
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,920
Total amount of fees paid to insurance company	USD $87
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Insurance broker organization code?	3
Amount paid for insurance broker fees	87
Insurance broker name	CBIZ BENEFITS & INS SERVICES INC

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

Policy contract number

GLUG0AVYW

Policy instance

Insurance contract or identification number	GLUG0AVYW
Number of Individuals Covered	178
Insurance policy start date	2015-02-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,095
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $611
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

GLTD0AVYW

Policy instance

Insurance contract or identification number	GLTD0AVYW
Number of Individuals Covered	178
Insurance policy start date	2015-02-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,878
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,049
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

0865473HNO-SHOR

Policy instance

Insurance contract or identification number	0865473HNO-SHOR
Number of Individuals Covered	183
Insurance policy start date	2014-01-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $3,754
Welfare Benefit Premiums Paid to Carrier	USD $60,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,754
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

0865473

Policy instance

Insurance contract or identification number	0865473
Number of Individuals Covered	11
Insurance policy start date	2014-01-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $205
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $205
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

591029 0001

Policy instance

Insurance contract or identification number	591029 0001
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,456
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $25,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,456
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

14513

Policy instance

Insurance contract or identification number	14513
Number of Individuals Covered	200
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $969
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $969
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	34
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,695
Total amount of fees paid to insurance company	USD $57
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,450
Insurance broker organization code?	3
Amount paid for insurance broker fees	57
Insurance broker name	MARK RIEDER

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

Policy contract number

R0093120

Policy instance

Insurance contract or identification number	R0093120
Number of Individuals Covered	7
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $997
Other welfare benefits provided	GCI
Welfare Benefit Premiums Paid to Carrier	USD $1,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $399
Insurance broker organization code?	3
Insurance broker name	MARK J REIDER

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

685441

Policy instance

Insurance contract or identification number	685441
Number of Individuals Covered	127
Insurance policy start date	2014-02-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,678
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,678
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

135707

Policy instance

Insurance contract or identification number	135707
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $483
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $3,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $483
Insurance broker organization code?	3
Insurance broker name	MODEL CONSULTING INC

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

Policy contract number

0865473

Policy instance

Insurance contract or identification number	0865473
Number of Individuals Covered	11
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,556
Total amount of fees paid to insurance company	USD $34
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

135707

Policy instance

Insurance contract or identification number	135707
Number of Individuals Covered	12
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $267
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $1,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

14513

Policy instance

Insurance contract or identification number	14513
Number of Individuals Covered	197
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,507
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000000591029

Policy instance

Insurance contract or identification number	000000591029
Number of Individuals Covered	145
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $3,248
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $28,274
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

0865473HNO

Policy instance

Insurance contract or identification number	0865473HNO
Number of Individuals Covered	188
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $35,668
Welfare Benefit Premiums Paid to Carrier	USD $683,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0008403988

Policy instance

Insurance contract or identification number	0008403988
Number of Individuals Covered	15
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $380
Total amount of fees paid to insurance company	USD $20
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SICOM SYSTEMS, INC.
Employer identification number (EIN):	232480489
NAIC Classification:	339900