401k Plan data: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN plan

HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	HABASIT AMERICA, INC. WELFARE BENEFIT PLAN
Plan identification number	506

HABASIT AMERICA, INC. WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

HABASIT AMERICA, INC. has sponsored the creation of one or more 401k plans.

Company Name: HABASIT AMERICA, INC.

Employer identification number (EIN): 233059540

NAIC Classification: 339900

Additional information about HABASIT AMERICA, INC.

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date: 2008-05-28

Company Identification Number: 1364049

Legal Registered Office Address: 805 SATELLITE BLVD.

Suwanee
United States of America (USA)
30024

More information about HABASIT AMERICA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HABASIT AMERICA, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2023-01-01 MAUREEN R. BEECHER 2024-10-01
506 2022-01-01 MAUREEN R. BEECHER 2023-05-31
506 2021-01-01 MAUREEN BEECHER 2022-07-26
506 2020-01-01 MAUREEN R. BEECHER 2021-06-16
506 2019-01-01
506 2018-01-01
506 2017-01-01 VICTOR DADAMIO
506 2016-01-01 VICTOR D'ADAMIO
506 2015-01-01 VICTOR D'ADAMIO
506 2014-01-01 VICTOR D'ADAMIO
506 2013-01-01 JOHN GLASSFORD
506 2012-01-01 JOHN GLASSFORD
506 2011-01-01 JOHN GLASSFORD
506 2010-01-01 JOHN GLASSFORD
506 2009-01-01 JOHN GLASSFORD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
506	2023-01-01	MAUREEN R. BEECHER	2024-10-01
506	2022-01-01	MAUREEN R. BEECHER	2023-05-31
506	2021-01-01	MAUREEN BEECHER	2022-07-26
506	2020-01-01	MAUREEN R. BEECHER	2021-06-16
506	2019-01-01
506	2018-01-01
506	2017-01-01	VICTOR DADAMIO
506	2016-01-01	VICTOR D'ADAMIO
506	2015-01-01	VICTOR D'ADAMIO
506	2014-01-01	VICTOR D'ADAMIO
506	2013-01-01	JOHN GLASSFORD
506	2012-01-01	JOHN GLASSFORD
506	2011-01-01	JOHN GLASSFORD
506	2010-01-01	JOHN GLASSFORD
506	2009-01-01	JOHN GLASSFORD

Plan Statistics for HABASIT AMERICA, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for HABASIT AMERICA, INC. WELFARE BENEFIT PLAN

Measure Date Value
2023: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 761
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 750
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 750
Number of employers contributing to the scheme 2023-01-01 0
2022: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 759
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 787
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 787
Number of employers contributing to the scheme 2022-01-01 0
2021: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 552
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 759
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 2021-01-01 759
Number of employers contributing to the scheme 2021-01-01 0
2020: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 596
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 552
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 2020-01-01 552
Number of employers contributing to the scheme 2020-01-01 0
2019: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 581
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 576
Number of retired or separated participants receiving benefits 2019-01-01 20
Total of all active and inactive participants 2019-01-01 596
2018: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 591
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 577
Number of retired or separated participants receiving benefits 2018-01-01 4
Total of all active and inactive participants 2018-01-01 581
2017: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 982
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 591
Total of all active and inactive participants 2017-01-01 591
2016: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 988
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 982
Total of all active and inactive participants 2016-01-01 982
2015: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 975
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 988
Total of all active and inactive participants 2015-01-01 988
2014: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,332
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 975
Total of all active and inactive participants 2014-01-01 975
2013: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,065
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,332
Total of all active and inactive participants 2013-01-01 1,332
2012: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,108
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,055
Number of retired or separated participants receiving benefits 2012-01-01 10
Total of all active and inactive participants 2012-01-01 1,065
2011: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 998
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,102
Number of retired or separated participants receiving benefits 2011-01-01 6
Total of all active and inactive participants 2011-01-01 1,108
2010: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 886
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 992
Number of retired or separated participants receiving benefits 2010-01-01 6
Total of all active and inactive participants 2010-01-01 998
Total participants 2010-01-01 998
2009: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 954
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 865
Number of retired or separated participants receiving benefits 2009-01-01 21
Total of all active and inactive participants 2009-01-01 886
Total participants 2009-01-01 886

Measure	Date	Value
2023: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	761
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	750
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	750
Number of employers contributing to the scheme	2023-01-01	0
2022: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	759
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	787
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	787
Number of employers contributing to the scheme	2022-01-01	0
2021: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	552
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	759
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	759
Number of employers contributing to the scheme	2021-01-01	0
2020: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	596
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	552
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	552
Number of employers contributing to the scheme	2020-01-01	0
2019: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	581
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	576
Number of retired or separated participants receiving benefits	2019-01-01	20
Total of all active and inactive participants	2019-01-01	596
2018: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	591
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	577
Number of retired or separated participants receiving benefits	2018-01-01	4
Total of all active and inactive participants	2018-01-01	581
2017: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	982
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	591
Total of all active and inactive participants	2017-01-01	591
2016: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	988
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	982
Total of all active and inactive participants	2016-01-01	982
2015: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	975
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	988
Total of all active and inactive participants	2015-01-01	988
2014: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,332
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	975
Total of all active and inactive participants	2014-01-01	975
2013: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,065
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,332
Total of all active and inactive participants	2013-01-01	1,332
2012: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,108
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,055
Number of retired or separated participants receiving benefits	2012-01-01	10
Total of all active and inactive participants	2012-01-01	1,065
2011: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	998
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,102
Number of retired or separated participants receiving benefits	2011-01-01	6
Total of all active and inactive participants	2011-01-01	1,108
2010: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	886
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	992
Number of retired or separated participants receiving benefits	2010-01-01	6
Total of all active and inactive participants	2010-01-01	998
Total participants	2010-01-01	998
2009: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	954
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	865
Number of retired or separated participants receiving benefits	2009-01-01	21
Total of all active and inactive participants	2009-01-01	886
Total participants	2009-01-01	886

Form 5500 Responses for HABASIT AMERICA, INC. WELFARE BENEFIT PLAN

2023: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan 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
2010: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HABASIT AMERICA, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
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

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

240320

Policy instance

Insurance contract or identification number	240320
Number of Individuals Covered	733
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $278,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5974215

Policy instance

Insurance contract or identification number	5974215
Number of Individuals Covered	787
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,410
Total amount of fees paid to insurance company	USD $2,132
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $171,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,410
Amount paid for insurance broker fees	2069
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5974215

Policy instance

Insurance contract or identification number	5974215
Number of Individuals Covered	759
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,618
Total amount of fees paid to insurance company	USD $4,301
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $231,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,618
Amount paid for insurance broker fees	4247
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	552
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $43,664
Total amount of fees paid to insurance company	USD $12,838
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $386,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,677
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	463
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Number of Individuals Covered	40
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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 $19,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	576
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $47,757
Total amount of fees paid to insurance company	USD $10,405
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $419,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,757
Amount paid for insurance broker fees	10405
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	427
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	511
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	577
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $40,834
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $357,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,834
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Insurance policy start date	2018-01-01
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	547
Insurance policy start date	2018-01-01
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	494
Insurance policy start date	2018-01-01
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

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	543
Insurance policy start date	2018-01-01
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Number of Individuals Covered	70
Insurance policy start date	2018-01-01
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 $35,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	958
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Number of Individuals Covered	76
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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 $20,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

20324

Policy instance

Insurance contract or identification number	20324
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	1048
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	591
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $47,561
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $368,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,239
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	NORTHWESTERN BENEFIT CORP OF GA

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

14008

Policy instance

Insurance contract or identification number	14008
Number of Individuals Covered	456
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	585
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $34,436
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $300,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,721
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	398
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $34,097
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $340,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,097
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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
Other welfare benefits provided	STOP LOSS INSURANCE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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
Other welfare benefits provided	STOP LOSS INSURANCE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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
Other welfare benefits provided	STOP LOSS INSURANCE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	988
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000THB01-16

Policy instance

Insurance contract or identification number	84000THB01-16
Number of Individuals Covered	988
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	432
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $20,920
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $209,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,920
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000THB01-16

Policy instance

Insurance contract or identification number	84000THB01-16
Number of Individuals Covered	949
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	975
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,944
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $29,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,944
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,541
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $65,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,541
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,370
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $33,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,370
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

232972

Policy instance

Insurance contract or identification number	232972
Number of Individuals Covered	292
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $31,893
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,893
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOC LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	1099
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	250
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $23,830
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $238,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,830
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	79
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,120
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $61,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,120
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	46
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,898
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $28,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,898
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	51
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,033
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $40,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,033
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

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

Policy contract number

GLUG0154F

Policy instance

Insurance contract or identification number	GLUG0154F
Number of Individuals Covered	494
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $91,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0154F

Policy instance

Insurance contract or identification number	GLTD0154F
Number of Individuals Covered	170
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0154F

Policy instance

Insurance contract or identification number	GVTL0154F
Number of Individuals Covered	154
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
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
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $67,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NOVA HEALTHCARE ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52524 )

Policy contract number

165,365,436,96

Policy instance

Insurance contract or identification number	165,365,436,96
Number of Individuals Covered	460
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84001T

Policy instance

Insurance contract or identification number	84001T
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0154F

Policy instance

Insurance contract or identification number	GUPR0154F
Number of Individuals Covered	103
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,397
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	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $23,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2397
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000THB01-16

Policy instance

Insurance contract or identification number	84000THB01-16
Number of Individuals Covered	637
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

Policy instance

Number of Individuals Covered	637
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	FLEX
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUSIB154F

Policy instance

Insurance contract or identification number	GUSIB154F
Number of Individuals Covered	411
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
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
Other welfare benefits provided	ADMINISTRATIVE SERVICES ONLY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84004T

Policy instance

Insurance contract or identification number	84004T
Number of Individuals Covered	181
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	271
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $22,523
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $225,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,523
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84003T

Policy instance

Insurance contract or identification number	84003T
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0154F

Policy instance

Insurance contract or identification number	GVTL0154F
Number of Individuals Covered	161
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
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
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $66,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84005T

Policy instance

Insurance contract or identification number	84005T
Number of Individuals Covered	58
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84006T

Policy instance

Insurance contract or identification number	84006T
Number of Individuals Covered	96
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0154F

Policy instance

Insurance contract or identification number	GUPR0154F
Number of Individuals Covered	106
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $2,351
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	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $23,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,351
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439F

Policy instance

Insurance contract or identification number	30439F
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439H

Policy instance

Insurance contract or identification number	30439H
Number of Individuals Covered	26
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439M

Policy instance

Insurance contract or identification number	30439M
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

15648

Policy instance

Insurance contract or identification number	15648
Number of Individuals Covered	1083
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84001T 04

Policy instance

Insurance contract or identification number	84001T 04
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84002T

Policy instance

Insurance contract or identification number	84002T
Number of Individuals Covered	19
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T HB15

Policy instance

Insurance contract or identification number	84000T HB15
Number of Individuals Covered	10
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84001T

Policy instance

Insurance contract or identification number	84001T
Number of Individuals Covered	31
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	52
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,983
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $29,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,983
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	54
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $5,849
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $58,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,849
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	35
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $3,273
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $32,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,273
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

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

Policy contract number

GUSIB154F

Policy instance

Insurance contract or identification number	GUSIB154F
Number of Individuals Covered	433
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
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
Other welfare benefits provided	ADMINISTRATIVE SERVICES ONLY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

PHARMACY BENEFIT DIMENSIONS INC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000THB01-16

Policy instance

Insurance contract or identification number	84000THB01-16
Number of Individuals Covered	1020
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0154F

Policy instance

Insurance contract or identification number	GLUG0154F
Number of Individuals Covered	490
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $91,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0154F

Policy instance

Insurance contract or identification number	GLTD0154F
Number of Individuals Covered	180
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NOVA HEALTHCARE ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52524 )

Policy contract number

165,365,436,96

Policy instance

Insurance contract or identification number	165,365,436,96
Number of Individuals Covered	463
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T

Policy instance

Insurance contract or identification number	84000T
Number of Individuals Covered	624
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84003T

Policy instance

Insurance contract or identification number	84003T
Number of Individuals Covered	11
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84004T

Policy instance

Insurance contract or identification number	84004T
Number of Individuals Covered	183
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84005T

Policy instance

Insurance contract or identification number	84005T
Number of Individuals Covered	61
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84006T

Policy instance

Insurance contract or identification number	84006T
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0154F

Policy instance

Insurance contract or identification number	GUPR0154F
Number of Individuals Covered	118
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $2,824
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	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $28,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439F

Policy instance

Insurance contract or identification number	30439F
Number of Individuals Covered	5
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439H

Policy instance

Insurance contract or identification number	30439H
Number of Individuals Covered	45
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $244,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30439M

Policy instance

Insurance contract or identification number	30439M
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84002T

Policy instance

Insurance contract or identification number	84002T
Number of Individuals Covered	11
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84001T

Policy instance

Insurance contract or identification number	84001T
Number of Individuals Covered	21
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	245
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $21,024
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $210,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	37
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $2,867
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $28,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	84
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $6,664
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $66,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	61
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $4,446
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
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $44,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUSIB154F

Policy instance

Insurance contract or identification number	GUSIB154F
Number of Individuals Covered	427
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
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
Other welfare benefits provided	ADMINISTRATIVE SERVICES ONLY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0154F

Policy instance

Insurance contract or identification number	GLUG0154F
Number of Individuals Covered	521
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $95,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0154F

Policy instance

Insurance contract or identification number	GLTD0154F
Number of Individuals Covered	186
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0154F

Policy instance

Insurance contract or identification number	GVTL0154F
Number of Individuals Covered	172
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
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
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $66,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NOVA HEALTHCARE ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52524 )

Policy contract number

165,365,436,96

Policy instance

Insurance contract or identification number	165,365,436,96
Number of Individuals Covered	466
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T

Policy instance

Insurance contract or identification number	84000T
Number of Individuals Covered	637
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T HB15

Policy instance

Insurance contract or identification number	84000T HB15
Number of Individuals Covered	10
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T

Policy instance

Insurance contract or identification number	84000T
Number of Individuals Covered	591
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84001T

Policy instance

Insurance contract or identification number	84001T
Number of Individuals Covered	24
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84000T HB15

Policy instance

Insurance contract or identification number	84000T HB15
Number of Individuals Covered	10
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84003T

Policy instance

Insurance contract or identification number	84003T
Number of Individuals Covered	12
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84004T

Policy instance

Insurance contract or identification number	84004T
Number of Individuals Covered	167
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84005T

Policy instance

Insurance contract or identification number	84005T
Number of Individuals Covered	57
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84006T

Policy instance

Insurance contract or identification number	84006T
Number of Individuals Covered	129
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NOVA HEALTHCARE ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52524 )

Policy contract number

#165,#365,#436,

Policy instance

Insurance contract or identification number	#165,#365,#436,
Number of Individuals Covered	508
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0154F

Policy instance

Insurance contract or identification number	GVTL0154F
Number of Individuals Covered	168
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $72,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0154F

Policy instance

Insurance contract or identification number	GLTD0154F
Number of Individuals Covered	186
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

84002T

Policy instance

Insurance contract or identification number	84002T
Number of Individuals Covered	8
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1038620001

Policy instance

Insurance contract or identification number	1038620001
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0010

Policy instance

Insurance contract or identification number	402031 0010
Number of Individuals Covered	244
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $11,913
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $119,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,913
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0020

Policy instance

Insurance contract or identification number	402031 0020
Number of Individuals Covered	34
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,670
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $16,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,670
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0030

Policy instance

Insurance contract or identification number	402031 0030
Number of Individuals Covered	81
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,786
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $37,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,786
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402031 0040

Policy instance

Insurance contract or identification number	402031 0040
Number of Individuals Covered	68
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $2,828
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	STOP LOSS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $28,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,828
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

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

Policy contract number

GUSIB154F

Policy instance

Insurance contract or identification number	GUSIB154F
Number of Individuals Covered	418
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Other welfare benefits provided	ADMINISTRATIVE SERVICES ONLY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0154F

Policy instance

Insurance contract or identification number	GLUG0154F
Number of Individuals Covered	511
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $89,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0154F

Policy instance

Insurance contract or identification number	GUPR0154F
Number of Individuals Covered	103
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Total amount of commissions paid to insurance broker	USD $1,992
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $19,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,992
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOCIATES

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Company Name:	HABASIT AMERICA, INC.
Employer identification number (EIN):	233059540
NAIC Classification:	339900

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:	2008-05-28
Company Identification Number:	1364049
Legal Registered Office Address:	805 SATELLITE BLVD. Suwanee United States of America (USA) 30024