401k Plan data: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS plan

ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 401k Plan overview

Plan Name	ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS
Plan identification number	501

ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 Other welfare benefit cover

401k Sponsoring company profile

ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. has sponsored the creation of one or more 401k plans.

Company Name: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.

Employer identification number (EIN): 232720289

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 LOREN STONE 2023-10-16
501 2021-01-01 LOREN STONE 2022-12-06
501 2020-01-01 LOREN STONE 2021-10-15
501 2020-01-01 LOREN STONE 2021-11-05
501 2019-01-01 LOREN STONE 2020-09-17
501 2018-01-01 LOREN STONE 2019-10-11
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 LOREN L. STONE
501 2011-01-01 REXFORD O. CATLIN, CEO
501 2009-01-01 REXFORD O. CATLIN
501 2009-01-01 REXFORD O. CATLIN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	LOREN STONE	2023-10-16
501	2021-01-01	LOREN STONE	2022-12-06
501	2020-01-01	LOREN STONE	2021-10-15
501	2020-01-01	LOREN STONE	2021-11-05
501	2019-01-01	LOREN STONE	2020-09-17
501	2018-01-01	LOREN STONE	2019-10-11
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	LOREN L. STONE
501	2011-01-01	REXFORD O. CATLIN, CEO
501	2009-01-01	REXFORD O. CATLIN
501	2009-01-01	REXFORD O. CATLIN

Plan Statistics for ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS

401k plan membership statisitcs for ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS

Measure Date Value
2022: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2022 401k membership
Total participants, beginning-of-year 2022-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 132
Total of all active and inactive participants 2022-01-01 132
2021: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2021 401k membership
Total participants, beginning-of-year 2021-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 140
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 140
2020: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2020 401k membership
Total participants, beginning-of-year 2020-01-01 149
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 138
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 138
2019: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2019 401k membership
Total participants, beginning-of-year 2019-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 149
Number of retired or separated participants receiving benefits 2019-01-01 3
Total of all active and inactive participants 2019-01-01 152
2018: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2018 401k membership
Total participants, beginning-of-year 2018-01-01 160
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 163
Number of retired or separated participants receiving benefits 2018-01-01 5
Total of all active and inactive participants 2018-01-01 168
2017: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2017 401k membership
Total participants, beginning-of-year 2017-01-01 137
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 156
Number of retired or separated participants receiving benefits 2017-01-01 4
Total of all active and inactive participants 2017-01-01 160
2016: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2016 401k membership
Total participants, beginning-of-year 2016-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 135
Number of retired or separated participants receiving benefits 2016-01-01 2
Total of all active and inactive participants 2016-01-01 137
2015: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 138
Number of retired or separated participants receiving benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 139
2014: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 127
Number of retired or separated participants receiving benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 129
2013: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 173
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 114
Number of retired or separated participants receiving benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 115
2012: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2012 401k membership
Total participants, beginning-of-year 2012-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 170
Number of retired or separated participants receiving benefits 2012-01-01 3
Total of all active and inactive participants 2012-01-01 173
2011: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2011 401k membership
Total participants, beginning-of-year 2011-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 120
Number of retired or separated participants receiving benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 122
2009: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2009 401k membership
Total participants, beginning-of-year 2009-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 157
Total of all active and inactive participants 2009-01-01 157

Measure	Date	Value
2022: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2022 401k membership
Total participants, beginning-of-year	2022-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	132
Total of all active and inactive participants	2022-01-01	132
2021: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2021 401k membership
Total participants, beginning-of-year	2021-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	140
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	140
2020: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2020 401k membership
Total participants, beginning-of-year	2020-01-01	149
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	138
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	138
2019: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2019 401k membership
Total participants, beginning-of-year	2019-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	149
Number of retired or separated participants receiving benefits	2019-01-01	3
Total of all active and inactive participants	2019-01-01	152
2018: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2018 401k membership
Total participants, beginning-of-year	2018-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	163
Number of retired or separated participants receiving benefits	2018-01-01	5
Total of all active and inactive participants	2018-01-01	168
2017: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2017 401k membership
Total participants, beginning-of-year	2017-01-01	137
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	156
Number of retired or separated participants receiving benefits	2017-01-01	4
Total of all active and inactive participants	2017-01-01	160
2016: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	135
Number of retired or separated participants receiving benefits	2016-01-01	2
Total of all active and inactive participants	2016-01-01	137
2015: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	138
Number of retired or separated participants receiving benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	139
2014: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	127
Number of retired or separated participants receiving benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	129
2013: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	173
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	114
Number of retired or separated participants receiving benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	115
2012: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	170
Number of retired or separated participants receiving benefits	2012-01-01	3
Total of all active and inactive participants	2012-01-01	173
2011: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	120
Number of retired or separated participants receiving benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	122
2009: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	157
Total of all active and inactive participants	2009-01-01	157

Form 5500 Responses for ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS

2022: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 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: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ENDLESS MOUNTAINS HEALTH SYSTEMS, INC. FLEXIBLE BENEFIT PLANS 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 funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term 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

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	27
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $3,316
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $21,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,376
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	132
Insurance policy start date	2021-11-01
Insurance policy end date	2022-11-01
Total amount of commissions paid to insurance broker	USD $1,160
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $875
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	10
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $599
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $2,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $599
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

61370-MNL

Policy instance

Insurance contract or identification number	61370-MNL
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	118
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,969
Total amount of fees paid to insurance company	USD $3,848
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,963
Amount paid for insurance broker fees	3397
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Number of Individuals Covered	24
Welfare Benefit Premiums Paid to Carrier	USD $23,638
Commission paid to Insurance Broker	USD $934
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	131
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,348
Total amount of fees paid to insurance company	USD $249
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,348
Amount paid for insurance broker fees	249
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	20
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,236
Total amount of fees paid to insurance company	USD $412
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,236
Amount paid for insurance broker fees	412
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	12
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $711
Total amount of fees paid to insurance company	USD $81
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $3,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $711
Amount paid for insurance broker fees	81
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

61370-MNL

Policy instance

Insurance contract or identification number	61370-MNL
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,485
Total amount of fees paid to insurance company	USD $891
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,485
Insurance broker organization code?	3
Amount paid for insurance broker fees	891
Additional information about fees paid to insurance broker	TPA FEES

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	120
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,776
Total amount of fees paid to insurance company	USD $7,210
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,776
Amount paid for insurance broker fees	7210

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Number of Individuals Covered	43
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $7,106
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $236,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,106
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Number of Individuals Covered	140
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $21,920
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $730,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,920
Insurance broker organization code?	3

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

Policy contract number

0JK13

Policy instance

Insurance contract or identification number	0JK13
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,500
Total amount of fees paid to insurance company	USD $49
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $19,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $695
Amount paid for insurance broker fees	35
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	24
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,721
Total amount of fees paid to insurance company	USD $197
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,721
Amount paid for insurance broker fees	197
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	14
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $817
Total amount of fees paid to insurance company	USD $58
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $4,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $817
Amount paid for insurance broker fees	58
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

61370-MNL

Policy instance

Insurance contract or identification number	61370-MNL
Number of Individuals Covered	32
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,509
Total amount of fees paid to insurance company	USD $905
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,509
Insurance broker organization code?	3
Amount paid for insurance broker fees	905
Additional information about fees paid to insurance broker	TPA FEES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	140
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,197
Total amount of fees paid to insurance company	USD $147
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,197
Amount paid for insurance broker fees	147
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $991
Total amount of fees paid to insurance company	USD $49
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $8,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Number of Individuals Covered	152
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $27,432
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $914,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,432
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

61370-MNL

Policy instance

Insurance contract or identification number	61370-MNL
Number of Individuals Covered	37
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,189
Total amount of fees paid to insurance company	USD $1,059
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,189
Insurance broker organization code?	3
Amount paid for insurance broker fees	1059
Additional information about fees paid to insurance broker	TPA FEES

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

10118128

Policy instance

Insurance contract or identification number	10118128
Number of Individuals Covered	38
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $6,860
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $228,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,860
Additional information about fees paid to insurance broker	ADMIN

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	19
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,200
Total amount of fees paid to insurance company	USD $115
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $6,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,200
Amount paid for insurance broker fees	115
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,948
Total amount of fees paid to insurance company	USD $202
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,948
Amount paid for insurance broker fees	202
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0415444

Policy instance

Insurance contract or identification number	0415444
Number of Individuals Covered	136
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,451
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $108,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,451
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	149
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,725
Total amount of fees paid to insurance company	USD $116
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,725
Amount paid for insurance broker fees	116
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	26
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,103
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $25,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $883
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	31
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,181
Total amount of fees paid to insurance company	USD $205
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $26,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,292
Amount paid for insurance broker fees	145
Insurance broker organization code?	3

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

Policy contract number

116792

Policy instance

Insurance contract or identification number	116792
Number of Individuals Covered	231
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $20,295
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,164,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,295
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

101181281015

Policy instance

Insurance contract or identification number	101181281015
Number of Individuals Covered	5
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

101181281014

Policy instance

Insurance contract or identification number	101181281014
Number of Individuals Covered	191
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $391,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

101181281008

Policy instance

Insurance contract or identification number	101181281008
Number of Individuals Covered	32
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $780
Total amount of fees paid to insurance company	USD $173
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $5,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $541
Insurance broker organization code?	3
Amount paid for insurance broker fees	173
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	26
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,659
Total amount of fees paid to insurance company	USD $518
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,355
Amount paid for insurance broker fees	518
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0415444

Policy instance

Insurance contract or identification number	0415444
Number of Individuals Covered	137
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $6,978
Total amount of fees paid to insurance company	USD $4,360
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $114,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,978
Amount paid for insurance broker fees	4360
Insurance broker organization code?	3

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

Policy contract number

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	46
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $3,545
Total amount of fees paid to insurance company	USD $1,043
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,577
Insurance broker organization code?	3
Amount paid for insurance broker fees	763
Additional information about fees paid to insurance broker	CLAIMS ADMINISTRATIVE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	166
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $1,301
Total amount of fees paid to insurance company	USD $355
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $11,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $908
Amount paid for insurance broker fees	355
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

404002224

Policy instance

Insurance contract or identification number	404002224
Number of Individuals Covered	19
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $602
Total amount of fees paid to insurance company	USD $45
Other welfare benefits provided	ACC
Welfare Benefit Premiums Paid to Carrier	USD $6,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $602
Insurance broker organization code?	3
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN AND BROWN OF FL

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	30
Insurance policy start date	2016-11-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,025
Total amount of fees paid to insurance company	USD $163
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,025
Insurance broker organization code?	3
Amount paid for insurance broker fees	163
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN AND BROWN OF FL

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0415444

Policy instance

Insurance contract or identification number	0415444
Number of Individuals Covered	124
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $6,957
Total amount of fees paid to insurance company	USD $6,541
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $115,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,956
Insurance broker organization code?	3
Amount paid for insurance broker fees	6541
Insurance broker name	CRAWFORD ASSOCIATES INC

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

Policy contract number

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	39
Insurance policy start date	2016-02-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $5,125
Total amount of fees paid to insurance company	USD $1,165
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,359
Insurance broker organization code?	3
Amount paid for insurance broker fees	827
Additional information about fees paid to insurance broker	CLAIMS AND ADMINISTRATIVE SERVICES
Insurance broker name	THE ABACUS GROUP LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	163
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $1,374
Total amount of fees paid to insurance company	USD $85
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,374
Insurance broker organization code?	3
Amount paid for insurance broker fees	85
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN AND BROWN OF FL

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

Policy contract number

116792

Policy instance

Insurance contract or identification number	116792
Number of Individuals Covered	225
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $19,596
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,308,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,596
Insurance broker organization code?	3
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	35
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,021
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $26,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,332
Insurance broker organization code?	3
Insurance broker name	MARK D BARBIER

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	127
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $6,493
Total amount of fees paid to insurance company	USD $4,671
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $108,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,461
Amount paid for insurance broker fees	4671
Insurance broker organization code?	3
Insurance broker name	CRAWFORD ASSOCIATES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	181
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,104
Total amount of fees paid to insurance company	USD $315
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,104
Insurance broker organization code?	3
Amount paid for insurance broker fees	315
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	55
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $6,060
Total amount of fees paid to insurance company	USD $1,253
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,864
Insurance broker organization code?	3
Amount paid for insurance broker fees	876
Additional information about fees paid to insurance broker	CLAIMS ADMINISTRATIVE SERVICE
Insurance broker name	THE ABACUS GROUP, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	36
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,809
Total amount of fees paid to insurance company	USD $441
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,809
Insurance broker organization code?	3
Amount paid for insurance broker fees	441
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	33
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,874
Total amount of fees paid to insurance company	USD $95
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $28,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,131
Amount paid for insurance broker fees	59
Insurance broker organization code?	3
Insurance broker name	MARK D. BARBIER

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1809940000

Policy instance

Insurance contract or identification number	1809940000
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 $13,717
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $783,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,717
Insurance broker organization code?	3
Insurance broker name	THE BENEFITS GROUP OF HAUDENSC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000404002224

Policy instance

Insurance contract or identification number	000404002224
Number of Individuals Covered	24
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $979
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
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $10,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $979
Insurance broker organization code?	3
Insurance broker name	ALPHA BENEFITS GROUP, INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	179
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,234
Total amount of fees paid to insurance company	USD $137
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,234
Amount paid for insurance broker fees	137
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF FL

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

116860

Policy instance

Insurance contract or identification number	116860
Number of Individuals Covered	12
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $1,638
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,638
Insurance broker organization code?	3
Insurance broker name	THE BENEFITS GROUP

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1809940000

Policy instance

Insurance contract or identification number	1809940000
Number of Individuals Covered	262
Insurance policy start date	2014-08-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,311
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $417,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,311
Insurance broker organization code?	3
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	126
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $6,243
Total amount of fees paid to insurance company	USD $4,029
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $102,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,212
Amount paid for insurance broker fees	4029
Insurance broker organization code?	3
Insurance broker name	CRAWFORD ASSOCIATES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	39
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,034
Total amount of fees paid to insurance company	USD $430
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 $13,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,034
Insurance broker organization code?	3
Amount paid for insurance broker fees	430
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	62
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $5,391
Total amount of fees paid to insurance company	USD $1,129
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,423
Insurance broker organization code?	3
Amount paid for insurance broker fees	813
Additional information about fees paid to insurance broker	CLAIMS ADMINISTRATIVE SERVICES
Insurance broker name	THE ABACUS GROUP, LLC

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

Policy contract number

OJK13

Policy instance

Insurance contract or identification number	OJK13
Number of Individuals Covered	35
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,700
Total amount of fees paid to insurance company	USD $37
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	INTENSIVE CARE, CANCER, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $20,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,150
Insurance broker organization code?	3
Amount paid for insurance broker fees	23
Insurance broker name	DIANNE L. MARTIN

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000404002224

Policy instance

Insurance contract or identification number	000404002224
Number of Individuals Covered	28
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,231
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $8,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,231
Insurance broker organization code?	3
Insurance broker name	ALPHA BENEFITS GROUP, INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	39
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,868
Total amount of fees paid to insurance company	USD $440
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 $19,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,868
Insurance broker organization code?	3
Amount paid for insurance broker fees	440
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	119
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $5,507
Total amount of fees paid to insurance company	USD $6,328
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $88,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,477
Amount paid for insurance broker fees	6328
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	CRAWFORD ASSOCIATES, INC.

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

1807520000

Policy instance

Insurance contract or identification number	1807520000
Number of Individuals Covered	0
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $88
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,524
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
Insurance broker organization code?	3
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1807520000

Policy instance

Insurance contract or identification number	1807520000
Number of Individuals Covered	212
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $27,739
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,109,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,739
Insurance broker organization code?	3
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010148182

Policy instance

Insurance contract or identification number	000010148182
Number of Individuals Covered	159
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $732
Total amount of fees paid to insurance company	USD $163
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $6,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $732
Amount paid for insurance broker fees	163
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF FL

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

Policy contract number

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	69
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $10,955
Total amount of fees paid to insurance company	USD $1,947
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,747
Insurance broker organization code?	3
Amount paid for insurance broker fees	454
Additional information about fees paid to insurance broker	MARKETING FEE
Insurance broker name	LE PHAN - THE L. WARNER COMPANIES

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00606693

Policy instance

Insurance contract or identification number	G00606693
Number of Individuals Covered	30
Insurance policy start date	2013-01-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $879
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $879
Insurance broker organization code?	3
Insurance broker name	ALPHA BENEFITS GROUP, INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00606693

Policy instance

Insurance contract or identification number	G00606693
Number of Individuals Covered	32
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,411
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,411
Insurance broker organization code?	3
Insurance broker name	ALPHA BENEFITS GROUP, INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	150
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,204
Total amount of fees paid to insurance company	USD $45
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $37,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,204
Insurance broker organization code?	3
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	BROWN & BROWN OF FL

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	119
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $5,692
Total amount of fees paid to insurance company	USD $5,271
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $92,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,661
Amount paid for insurance broker fees	5271
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	CRAWFORD ASSOCIATES, INC.

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

1807520000

Policy instance

Insurance contract or identification number	1807520000
Number of Individuals Covered	2
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $337
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $337
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1807520000

Policy instance

Insurance contract or identification number	1807520000
Number of Individuals Covered	217
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $31,369
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,045,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,369
Insurance broker organization code?	3
Insurance broker name	BENEFITS GROUP OF HAUDENSCHIELD

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	24
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00606693

Policy instance

Insurance contract or identification number	G00606693
Number of Individuals Covered	28
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,262
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

052615,201256-7

Policy instance

Insurance contract or identification number	052615,201256-7
Number of Individuals Covered	201
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	66
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $3,002
Total amount of fees paid to insurance company	USD $793
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

3692545104

Policy instance

Insurance contract or identification number	3692545104
Number of Individuals Covered	0
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,428
Total amount of fees paid to insurance company	USD $10
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00415444

Policy instance

Insurance contract or identification number	00415444
Number of Individuals Covered	118
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $5,629
Total amount of fees paid to insurance company	USD $5,807
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $89,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0041544

Policy instance

Insurance contract or identification number	0041544
Number of Individuals Covered	123
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,192
Total amount of fees paid to insurance company	USD $4,272
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $91,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,156
Amount paid for insurance broker fees	4272
Insurance broker organization code?	3
Insurance broker name	CRAWFORD ASSOCIATES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400003001 00036

Policy instance

Insurance contract or identification number	400003001 00036
Number of Individuals Covered	24
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,644
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 $10,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,644
Insurance broker organization code?	3
Insurance broker name	ALPHA BENEFITS GROUP, INC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00606693

Policy instance

Insurance contract or identification number	G00606693
Number of Individuals Covered	30
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,318
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,318
Insurance broker name	ALPHA BENEFITS GROUP, INC

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

052615,201256-7

Policy instance

Insurance contract or identification number	052615,201256-7
Number of Individuals Covered	202
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

7007086

Policy instance

Insurance contract or identification number	7007086
Number of Individuals Covered	38
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $3,017
Total amount of fees paid to insurance company	USD $1,206
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,503
Insurance broker organization code?	3
Amount paid for insurance broker fees	58
Additional information about fees paid to insurance broker	MARKETING FEE
Insurance broker name	TOWERS PERRIN FORSTER & CROSBY, INC

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

3692545104

Policy instance

Insurance contract or identification number	3692545104
Number of Individuals Covered	159
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,683
Total amount of fees paid to insurance company	USD $10
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	TRAVEL AND OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	IBSI HOLDINGS, INC.

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Company Name:	ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.
Employer identification number (EIN):	232720289
NAIC Classification:	622000
NAIC Description:	Hospitals